Provider Demographics
NPI:1821603267
Name:SMITH, SHANNON ALEXANDRIA (RD)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:ALEXANDRIA
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 1:20621 NE 1ST CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-1702
Mailing Address - Country:US
Mailing Address - Phone:305-807-8622
Mailing Address - Fax:
Practice Address - Street 1:20621 NE 1ST CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33179-1702
Practice Address - Country:US
Practice Address - Phone:305-807-8622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-12
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND7999133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLND7999OtherLICENSE NUMBER