Provider Demographics
NPI:1275884801
Name:SMITH, VERA (LPN)
Entity Type:Individual
Prefix:MS
First Name:VERA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:VERA
Other - Middle Name:
Other - Last Name:VARDISHVILI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19 TUTHILL POINT RD
Mailing Address - Street 2:
Mailing Address - City:EAST MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11940-1216
Mailing Address - Country:US
Mailing Address - Phone:631-220-6031
Mailing Address - Fax:631-846-6665
Practice Address - Street 1:19 TUTHILL POINT RD
Practice Address - Street 2:
Practice Address - City:EAST MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11940-1216
Practice Address - Country:US
Practice Address - Phone:631-220-6031
Practice Address - Fax:631-846-6665
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-22
Last Update Date:2012-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311582164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse