Basic Information
| Provider Information | |||||||||
| NPI: | 1598980260 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | BRUNNER | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 SUNSET LN | ||||||||
| Address2: | |||||||||
| City: | MOUNT MORRIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610541101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156250400 | ||||||||
| FaxNumber: | 8156220473 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E LE FEVRE RD | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610811278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156250400 | ||||||||
| FaxNumber: | 8156220473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | IL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.