Provider Demographics
NPI:1124546502
Name:SMITH, STEPHANNI CHRISTINE
Entity Type:Individual
Prefix:
First Name:STEPHANNI
Middle Name:CHRISTINE
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 1:697 LAKENGREN CV
Mailing Address - Street 2:
Mailing Address - City:EATON
Mailing Address - State:OH
Mailing Address - Zip Code:45320-2515
Mailing Address - Country:US
Mailing Address - Phone:937-248-4310
Mailing Address - Fax:
Practice Address - Street 1:1 COLLEGE AND MAIN
Practice Address - Street 2:
Practice Address - City:BEXLEY
Practice Address - State:OH
Practice Address - Zip Code:43209-7812
Practice Address - Country:US
Practice Address - Phone:614-236-6011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer