Provider Demographics
NPI:1386984797
Name:SMITH, BECKY C (RD)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:C
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 1:701 N 1ST ST
Mailing Address - Street 2:FOOD & NUTRITION
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62781-0001
Mailing Address - Country:US
Mailing Address - Phone:217-788-3477
Mailing Address - Fax:
Practice Address - Street 1:701 N 1ST ST
Practice Address - Street 2:FOOD & NUTRITION
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-0001
Practice Address - Country:US
Practice Address - Phone:217-788-3477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164002310133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL934455OtherCDR