Provider Demographics
NPI:1922636810
Name:SMITH, SHANNON (RD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
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 1:1516 E ROVEY AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2441
Mailing Address - Country:US
Mailing Address - Phone:214-606-9056
Mailing Address - Fax:
Practice Address - Street 1:1955 W FRYE RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6282
Practice Address - Country:US
Practice Address - Phone:480-728-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-28
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL921653133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered