Provider Demographics
NPI:1043690894
Name:SMITH, TANIELLE BREW (MD)
Entity Type:Individual
Prefix:
First Name:TANIELLE
Middle Name:BREW
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-633-0340
Mailing Address - Fax:904-633-0341
Practice Address - Street 1:3122 NEW BERLIN RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32226-1828
Practice Address - Country:US
Practice Address - Phone:904-633-0340
Practice Address - Fax:904-633-0341
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN 21895207Q00000X
FLME129374207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine