Provider Demographics
NPI:1225510472
Name:SMITH, GENEVA (CNA/CMA/RA)
Entity Type:Individual
Prefix:
First Name:GENEVA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNA/CMA/RA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 S BLUFFVIEW DR APT 221
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-3015
Mailing Address - Country:US
Mailing Address - Phone:316-559-5194
Mailing Address - Fax:
Practice Address - Street 1:1324 S BLUFFVIEW DR APT 221
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-3015
Practice Address - Country:US
Practice Address - Phone:316-559-5194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS151861172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker