Provider Demographics
NPI:1275020091
Name:SMITH, TINA SUZETTE (LVN)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:SUZETTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 JAYCEE DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-5801
Mailing Address - Country:US
Mailing Address - Phone:903-238-9523
Mailing Address - Fax:903-212-4918
Practice Address - Street 1:1105 TOWN LAKE DR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-4927
Practice Address - Country:US
Practice Address - Phone:903-220-9901
Practice Address - Fax:903-212-4918
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX140651164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse