Provider Demographics
NPI:1629793401
Name:SMITH, LYDIA ABIGAIL (RDN, LDN)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:ABIGAIL
Last Name:SMITH
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 RUBY R CT
Mailing Address - Street 2:
Mailing Address - City:JONESBOROUGH
Mailing Address - State:TN
Mailing Address - Zip Code:37659-4655
Mailing Address - Country:US
Mailing Address - Phone:318-510-6773
Mailing Address - Fax:
Practice Address - Street 1:150 RUBY R CT
Practice Address - Street 2:
Practice Address - City:JONESBOROUGH
Practice Address - State:TN
Practice Address - Zip Code:37659-4655
Practice Address - Country:US
Practice Address - Phone:318-510-6773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3452133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered