Provider Demographics
NPI:1992456917
Name:SMITH, MARA (RD, LDN)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 SE OAKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-5134
Mailing Address - Country:US
Mailing Address - Phone:561-693-9323
Mailing Address - Fax:
Practice Address - Street 1:316 SE OAKRIDGE DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-5134
Practice Address - Country:US
Practice Address - Phone:561-693-9323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND10917133VN1005X, 133VN1006X, 133VN1201X, 133VN1301X, 133VN1501X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
No133VN1301XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Oncology
No133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics