Provider Demographics
NPI:1114254331
Name:SMITH, MYRNA RACHELLE (LAC)
Entity Type:Individual
Prefix:MS
First Name:MYRNA
Middle Name:RACHELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9661 CLOVERCROFT RD
Mailing Address - Street 2:
Mailing Address - City:NOLENSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37135-9449
Mailing Address - Country:US
Mailing Address - Phone:407-267-1154
Mailing Address - Fax:
Practice Address - Street 1:1731 MALLORY LN STE 109
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-7986
Practice Address - Country:US
Practice Address - Phone:615-953-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-09
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 2723171100000X
TNACU0362171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist