Provider Demographics
NPI:1174296313
Name:SMITH, CALLY MICHELLE
Entity Type:Individual
Prefix:
First Name:CALLY
Middle Name:MICHELLE
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 1:2715 40TH ST E APT D
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98404-5335
Mailing Address - Country:US
Mailing Address - Phone:253-686-5434
Mailing Address - Fax:
Practice Address - Street 1:3124 S 19TH ST STE 220
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2433
Practice Address - Country:US
Practice Address - Phone:253-301-5050
Practice Address - Fax:253-301-5070
Is Sole Proprietor?:No
Enumeration Date:2021-07-25
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAPA61350382363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program