Provider Demographics
NPI:1962176610
Name:SMITH-WILSON, RICHELLE (CNS)
Entity type:Individual
Prefix:
First Name:RICHELLE
Middle Name:
Last Name:SMITH-WILSON
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3344
Mailing Address - Country:US
Mailing Address - Phone:504-352-7297
Mailing Address - Fax:
Practice Address - Street 1:1608 PLAZA DR
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3344
Practice Address - Country:US
Practice Address - Phone:504-352-7297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1722279133V00000X
LA1722277225700000X
LA1722278174200000X, 133N00000X
LA172277174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No174200000XOther Service ProvidersMeals
No174H00000XOther Service ProvidersHealth Educator
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPENDINGMedicaid