Provider Demographics
NPI:1740011493
Name:SMITH, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 N DREAMY DRAW DR STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4668
Mailing Address - Country:US
Mailing Address - Phone:480-882-4545
Mailing Address - Fax:602-490-0499
Practice Address - Street 1:8705 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85257-3909
Practice Address - Country:US
Practice Address - Phone:480-882-4545
Practice Address - Fax:480-405-8929
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86144665133V00000X
AZ86144665133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered