Healthcare Provider Details

I. General information

NPI: 1992456917
Provider Name (Legal Business Name): MARA SMITH RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 SE OAKRIDGE DR
PORT ST LUCIE FL
34984-5134
US

IV. Provider business mailing address

316 SE OAKRIDGE DR
PORT ST LUCIE FL
34984-5134
US

V. Phone/Fax

Practice location:
  • Phone: 561-693-9323
  • Fax:
Mailing address:
  • Phone: 561-693-9323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberND10917
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberND10917
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberND10917
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code133VN1301X
TaxonomyOncology Nutrition Registered Dietitian
License NumberND10917
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License NumberND10917
License Number StateFL
# 6
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND10917
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: