Provider Demographics
NPI:1972622512
Name:ADAMS SMITH, KRISTINA D (RD)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:D
Last Name:ADAMS 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 1:1005 HEALTH CENTER DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938
Mailing Address - Country:US
Mailing Address - Phone:217-238-4774
Mailing Address - Fax:217-238-4775
Practice Address - Street 1:1005 HEALTH CENTER DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938
Practice Address - Country:US
Practice Address - Phone:217-238-4774
Practice Address - Fax:217-238-4775
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.003450133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6447860004Medicare NSC
ILIL3270541Medicare PIN
IL200810001Medicare PIN