Provider Demographics
NPI:1982187571
Name:SMITH, ELIZABETH BLACK (RD, LDN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BLACK
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5821 FAIRVIEW ROAD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209
Mailing Address - Country:US
Mailing Address - Phone:980-224-3514
Mailing Address - Fax:
Practice Address - Street 1:5821 FAIRVIEW ROAD
Practice Address - Street 2:SUITE 216
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209
Practice Address - Country:US
Practice Address - Phone:980-224-3514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005574133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered