Provider Demographics
NPI:1912534256
Name:SMITH, MARY MARGARET (RDN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MARGARET
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 1:756 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53050-1704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:756 FOREST DR
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:WI
Practice Address - Zip Code:53050-1704
Practice Address - Country:US
Practice Address - Phone:920-387-2169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI610342133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered