Provider Demographics
NPI:1215109152
Name:SMITH, KERRI LYNN (RD)
Entity type:Individual
Prefix:MS
First Name:KERRI
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8550 PARKS RD
Mailing Address - Street 2:
Mailing Address - City:OVID
Mailing Address - State:MI
Mailing Address - Zip Code:48866-8626
Mailing Address - Country:US
Mailing Address - Phone:517-256-1607
Mailing Address - Fax:
Practice Address - Street 1:826 W KING ST
Practice Address - Street 2:SUITE R
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2120
Practice Address - Country:US
Practice Address - Phone:989-729-4509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI717192133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION54100OtherMEDICARE PART B MNT
MIN54100-002Medicare PIN