Healthcare Provider Details

I. General information

NPI: 1295375541
Provider Name (Legal Business Name): MS. MARY DARLENE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DR WARREN TUTTLE DR
HARRISBURG IL
62946-2718
US

IV. Provider business mailing address

208 RED ROW
MARION IL
62959-5320
US

V. Phone/Fax

Practice location:
  • Phone: 618-253-7671
  • Fax: 618-253-7104
Mailing address:
  • Phone: 618-579-8993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.002899
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: