Provider Demographics
NPI:1790451128
Name:SMALLEY, SUE ANN (RDN)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:ANN
Last Name:SMALLEY
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 1:182 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KENT CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49330-8938
Mailing Address - Country:US
Mailing Address - Phone:616-862-1363
Mailing Address - Fax:
Practice Address - Street 1:231 W PINE LAKE DR
Practice Address - Street 2:
Practice Address - City:NEWAYGO
Practice Address - State:MI
Practice Address - Zip Code:49337-9264
Practice Address - Country:US
Practice Address - Phone:231-652-4618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
850996133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered