Provider Demographics
NPI:1700579927
Name:SMITH, KELSEY LAUREN (RD, LDN, CLC)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:LAUREN
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD, LDN, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9119 COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-4270
Mailing Address - Country:US
Mailing Address - Phone:813-431-0023
Mailing Address - Fax:
Practice Address - Street 1:9119 COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-4270
Practice Address - Country:US
Practice Address - Phone:813-431-0023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11326133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered