MEDICARE: SHANNON SMITH RD, LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1396451829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON SMITH RD, LD

Provider Business Mailing Address
First Line	:	830 W SOUTH BOUNDARY ST STE A
Second Line	:
City	:	PERRYSBURG
State	:	OH
Zip	:	43551-5238
Country	:	US
Telephone Number	:	607-215-5070
Fax Number	:

Provider Business Practice Location Address
First Line	:	830 W SOUTH BOUNDARY ST STE A
Second Line	:
City	:	PERRYSBURG
State	:	OH
Zip	:	43551-5238
Country	:	US
Telephone Number	:	419-237-4868
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2023
Last Update Date	:	06/02/2026

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