Healthcare Provider Details

I. General information

NPI: 1245922996
Provider Name (Legal Business Name): LEANNE MICHELE SMITH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 ORONOCO ST STE 119B
ALEXANDRIA VA
22314-2091
US

IV. Provider business mailing address

215 E GLENDALE AVE APT 2
ALEXANDRIA VA
22301-1828
US

V. Phone/Fax

Practice location:
  • Phone: 919-741-7547
  • Fax:
Mailing address:
  • Phone: 919-741-7547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX6095
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: