Basic Information
| Provider Information | |||||||||
| NPI: | 1407347297 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | BANUELOS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS RD LD CDE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BANUELOS | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 447 LAKEDALE DR | ||||||||
| Address2: | |||||||||
| City: | MURPHY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750944289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4697340822 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5308 N GALLOWAY AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | MESQUITE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751501125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143582300 | ||||||||
| FaxNumber: | 2145796754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2018 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DT05851 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | DT05851 | 01 | TX | REGISTERED DIETITIAN | OTHER |