Provider Demographics
NPI:1164104543
Name:SMITH, CHANIQUA DOMINIQUE
Entity Type:Individual
Prefix:
First Name:CHANIQUA
Middle Name:DOMINIQUE
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 1:956 MOLLY BARR RD APT 2
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-2164
Mailing Address - Country:US
Mailing Address - Phone:662-801-2950
Mailing Address - Fax:
Practice Address - Street 1:956 MOLLY BARR RD APT 2
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655
Practice Address - Country:US
Practice Address - Phone:166-280-1295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906158363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health