Healthcare Provider Details

I. General information

NPI: 1174772214
Provider Name (Legal Business Name): NANCY SMALL MS RD L/DN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2008
Last Update Date: 11/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 BRIDGEPOINTE CIR UNIT 40
VERO BEACH FL
32967-6849
US

IV. Provider business mailing address

1915 BRIDGEPOINTE CIR UNIT 40
VERO BEACH FL
32967-6849
US

V. Phone/Fax

Practice location:
  • Phone: 716-861-5349
  • Fax:
Mailing address:
  • Phone: 716-861-5349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2733-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND6471
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number2733-1
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License NumberND 6471
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: