Healthcare Provider Details

I. General information

NPI: 1235208968
Provider Name (Legal Business Name): SHARON LOUISE SMITH RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHARON LOUISE MASSIE RD,LD

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 18TH ST E
HASTINGS MN
55033-3680
US

IV. Provider business mailing address

1556 OAKWOOD DR
SHOREVIEW MN
55126-8554
US

V. Phone/Fax

Practice location:
  • Phone: 651-438-8518
  • Fax: 651-437-2012
Mailing address:
  • Phone: 651-784-3845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1333
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: