Basic Information
| Provider Information | |||||||||
| NPI: | 1770779738 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RD,LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655369210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175336100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655369210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175336100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2007 | ||||||||
| LastUpdateDate: | 09/24/2007 | ||||||||
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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 | 2006027548 | MO | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.