Provider Demographics
NPI:1760583454
Name:SMITH, MICHELLE R (RD)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 584
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:NH
Mailing Address - Zip Code:03070-0584
Mailing Address - Country:US
Mailing Address - Phone:401-556-9396
Mailing Address - Fax:603-487-1419
Practice Address - Street 1:107 S RIVER RD #332
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6784
Practice Address - Country:US
Practice Address - Phone:401-556-9396
Practice Address - Fax:603-487-1419
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0660133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIR0216Medicare PIN