Provider Demographics
NPI:1679086565
Name:SMITH, ELISA A (RDN LDN)
Entity Type:Individual
Prefix:MRS
First Name:ELISA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:RDN LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2941 BATTLEGROUND AVE UNIT 39194
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27438-1004
Mailing Address - Country:US
Mailing Address - Phone:336-601-6287
Mailing Address - Fax:
Practice Address - Street 1:229 N GREENE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-2410
Practice Address - Country:US
Practice Address - Phone:336-601-6287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-14
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004938133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered