Provider Demographics
NPI:1386942241
Name:SMITH, SUSAN LYNN (MBA, RD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MBA, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 411
Mailing Address - Street 2:
Mailing Address - City:KALAHEO
Mailing Address - State:HI
Mailing Address - Zip Code:96741-0411
Mailing Address - Country:US
Mailing Address - Phone:808-212-4657
Mailing Address - Fax:
Practice Address - Street 1:3651 KAKELA MAKAI DRIVE
Practice Address - Street 2:
Practice Address - City:KALAHEO
Practice Address - State:HI
Practice Address - Zip Code:96741-0411
Practice Address - Country:US
Practice Address - Phone:808-212-4657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
722149133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
722149OtherCREDENTIALING AGENCY OF THE AMERICAN DIETETIC ASSOCIATION