Healthcare Provider Details

I. General information

NPI: 1447773783
Provider Name (Legal Business Name): MARIE G SMITH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 4TH ST
KEWAUNEE WI
54216
US

IV. Provider business mailing address

744 S WEBSTER AVE
GREEN BAY WI
54301-3505
US

V. Phone/Fax

Practice location:
  • Phone: 920-388-4640
  • Fax: 920-388-0479
Mailing address:
  • Phone: 920-445-7226
  • Fax: 920-445-7229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2305-029
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: