MEDICARE: MISS WINIFRED SMITH RD, CDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist		NY
2	133V00000X	Registered Dietitian	713069	IL

General Provider Information

NPI Number	:	1124397716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS WINIFRED SMITH RD, CDN

Provider Business Mailing Address
First Line	:	3119 FARRAGUT RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-2639
Country	:	US
Telephone Number	:	917-848-3964
Fax Number	:

Provider Business Practice Location Address
First Line	:	3119 FARRAGUT RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-2639
Country	:	US
Telephone Number	:	917-848-3964
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2011
Last Update Date	:	12/28/2011

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