Provider Demographics
NPI:1720237084
Name:SMITH, TANYA L (RD)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:L
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 1:503 WOODS MANOR DR
Mailing Address - Street 2:
Mailing Address - City:FREEBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62243-4073
Mailing Address - Country:US
Mailing Address - Phone:618-539-9888
Mailing Address - Fax:
Practice Address - Street 1:503 WOODS MANOR DR
Practice Address - Street 2:
Practice Address - City:FREEBURG
Practice Address - State:IL
Practice Address - Zip Code:62243-4073
Practice Address - Country:US
Practice Address - Phone:618-539-9888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004017627133V00000X
IL164.002959133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1861674871OtherADVANCED MEDICIAL SOLUTIONS, LLC D/B/A INSIGHT DIETITIANS
ILIL5797OtherADVANCED MEDICAL SOLUTIONS, LLC MEDICARE PIN
MOMA 2877OtherADVANCED MEDICAL SOLUTIONS, LLC MEDICARE PIN