Provider Demographics
NPI:1083298038
Name:SMITH, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
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 1802
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:WV
Mailing Address - Zip Code:25621-1802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26 GILBERT PARISH DRIVE
Practice Address - Street 2:APT 26
Practice Address - City:GILBERT
Practice Address - State:WV
Practice Address - Zip Code:25621-2562
Practice Address - Country:US
Practice Address - Phone:681-587-0858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker