Provider Demographics
NPI:1366268831
Name:SMITH, ELISE (RD)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:
Other - Last Name:BLICKENSDERFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:320 32ND AVE W STE 285
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:320 32ND AVE W STE 285
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-8372
Practice Address - Country:US
Practice Address - Phone:701-866-2163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-29
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1625133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered