Provider Demographics
NPI:1073106365
Name:SMITH, MELINDA ANN
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
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 1425
Mailing Address - Street 2:
Mailing Address - City:HOLLY HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29059-1425
Mailing Address - Country:US
Mailing Address - Phone:843-701-2690
Mailing Address - Fax:
Practice Address - Street 1:164 UNDERBUSH CT
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:SC
Practice Address - Zip Code:29059-8381
Practice Address - Country:US
Practice Address - Phone:843-701-2690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-1381253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care