Provider Demographics
NPI:1154081941
Name:SMITH, TAMARA LYNNE
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:LYNNE
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 1:1475 WOODLAKE DR APT 222
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-7140
Mailing Address - Country:US
Mailing Address - Phone:912-425-4906
Mailing Address - Fax:
Practice Address - Street 1:1015 N COMBEE RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-2913
Practice Address - Country:US
Practice Address - Phone:912-245-4906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL410668376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide