Provider Demographics
NPI:1083238174
Name:SMITH, KATIE GRACE (OD)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:GRACE
Last Name:SMITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 THOMASWOOD CHASE
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-9542
Mailing Address - Country:US
Mailing Address - Phone:731-607-3045
Mailing Address - Fax:
Practice Address - Street 1:220 N CHANCERY ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-2551
Practice Address - Country:US
Practice Address - Phone:931-473-2487
Practice Address - Fax:931-473-8782
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3593152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty