Provider Demographics
NPI:1740801232
Name:SMITH, AMY (MS, CNS, LDN, BCHN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, CNS, LDN, BCHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:553 WYNDALE RD
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-4721
Mailing Address - Country:US
Mailing Address - Phone:423-863-3072
Mailing Address - Fax:
Practice Address - Street 1:10451 MILL RUN CIR STE 400
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5594
Practice Address - Country:US
Practice Address - Phone:276-475-8848
Practice Address - Fax:276-222-6916
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEDN-0010852133V00000X, 133N00000X
MDDX5177133V00000X, 133N00000X
133N00000X
VACNS18228133N00000X
IL164.00899133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist