Healthcare Provider Details

I. General information

NPI: 1962046508
Provider Name (Legal Business Name): SIDNEY SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 09/04/2023
Certification Date: 09/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23401 PRAIRIE STAR PKWY STE B-300
LENEXA KS
66227-7268
US

IV. Provider business mailing address

23401 PRAIRIE STAR PKWY STE 300
LENEXA KS
66227-7246
US

V. Phone/Fax

Practice location:
  • Phone: 913-677-6319
  • Fax:
Mailing address:
  • Phone: 913-677-6319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number2018006451
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number2160
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: