Provider Demographics
NPI:1124394473
Name:SMITH, TANISHA (LPN)
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 W 34TH CT
Mailing Address - Street 2:APT 3
Mailing Address - City:GRIFFITH
Mailing Address - State:IN
Mailing Address - Zip Code:46319-1023
Mailing Address - Country:US
Mailing Address - Phone:708-238-2166
Mailing Address - Fax:
Practice Address - Street 1:211 W 34TH CT
Practice Address - Street 2:APT 3
Practice Address - City:GRIFFITH
Practice Address - State:IN
Practice Address - Zip Code:46319-1023
Practice Address - Country:US
Practice Address - Phone:708-238-2166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.109384164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse