Healthcare Provider Details

I. General information

NPI: 1962958785
Provider Name (Legal Business Name): SUZANNE SMITH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

IV. Provider business mailing address

4420 LAKE BOONE TRAIL
RALEIGH NC
27607
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-6594
  • Fax: 919-784-3180
Mailing address:
  • Phone: 919-784-6594
  • Fax: 919-784-3180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL001731
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: