Provider Demographics
NPI:1134698251
Name:SMITH, COURTNEY ROSE (RD, LD)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ROSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 NE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIMES
Mailing Address - State:IA
Mailing Address - Zip Code:50111-1107
Mailing Address - Country:US
Mailing Address - Phone:515-782-9990
Mailing Address - Fax:
Practice Address - Street 1:4911 SW 19TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50315-4487
Practice Address - Country:US
Practice Address - Phone:515-782-9990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA090714133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered