=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326585407
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN A SMITH LDN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2017
-----------------------------------------------------
Last Update Date | 01/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1114 HIDDEN SPRING DR
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60540-4112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-935-7497
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1114 HIDDEN SPRING DR
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60540-4112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number | 164.006976
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------