Provider Demographics
NPI:1891263968
Name:SMITH, MADISON HANNAH (RD, LD)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:HANNAH
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 W MAINE AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-5140
Mailing Address - Country:US
Mailing Address - Phone:714-262-0645
Mailing Address - Fax:
Practice Address - Street 1:1000 W BOISE CIR FL 3
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-4900
Practice Address - Country:US
Practice Address - Phone:918-994-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86106643133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered