Provider Demographics
NPI:1255532495
Name:SMITH, STACY M (RD,LD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 WALDROP TRL
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-7463
Mailing Address - Country:US
Mailing Address - Phone:404-229-2768
Mailing Address - Fax:
Practice Address - Street 1:261 PARKWAY DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1210
Practice Address - Country:US
Practice Address - Phone:404-265-6468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002671133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered