Healthcare Provider Details

I. General information

NPI: 1811859531
Provider Name (Legal Business Name): KRISTIE BLAKE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1597 S 1760 E
SPANISH FORK UT
84660-6505
US

IV. Provider business mailing address

1597 S 1760 E
SPANISH FORK UT
84660-6505
US

V. Phone/Fax

Practice location:
  • Phone: 540-817-7510
  • Fax:
Mailing address:
  • Phone: 540-817-7510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number5049707-4901
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: