Provider Demographics
NPI:1740791961
Name:SMITH, MARY (RDN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:8100 BOONE BLVD STE 700
Practice Address - Street 2:
Practice Address - City:TYSONS
Practice Address - State:VA
Practice Address - Zip Code:22182-2683
Practice Address - Country:US
Practice Address - Phone:240-670-5115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-15
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDI100000929133V00000X
VA86093641133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered