Healthcare Provider Details

I. General information

NPI: 1174255814
Provider Name (Legal Business Name): SHAWNA J SMOOT RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAWNA J KONEMANN

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 N MAIN ST
SPEARFISH SD
57783-1505
US

IV. Provider business mailing address

428 GOOSEBERRY RD
SPEARFISH SD
57783-9008
US

V. Phone/Fax

Practice location:
  • Phone: 605-644-4072
  • Fax:
Mailing address:
  • Phone: 480-285-5662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0828
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: