Provider Demographics
NPI:1891442208
Name:SMITH, HEIDI MARIE (RDN)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:MARIE
Last Name:SMITH
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 1:3711 LONG BEACH BLVD STE 904
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3324
Mailing Address - Country:US
Mailing Address - Phone:562-424-4055
Mailing Address - Fax:866-403-6068
Practice Address - Street 1:3711 LONG BEACH BLVD STE 904
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3324
Practice Address - Country:US
Practice Address - Phone:562-424-4055
Practice Address - Fax:866-403-6068
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-05
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN007672133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered