Provider Demographics
NPI:1194225052
Name:SMITH, PHYLLIS MARIE
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:MARIE
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 1:2401 SOUTHERN AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-4253
Mailing Address - Country:US
Mailing Address - Phone:202-486-4627
Mailing Address - Fax:
Practice Address - Street 1:1907 18TH ST SE APT 201
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-4653
Practice Address - Country:US
Practice Address - Phone:202-486-4627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-17
Last Update Date:2018-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant