Provider Demographics
NPI:1295818243
Name:SMITH, DEWANNA L
Entity Type:Individual
Prefix:
First Name:DEWANNA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOE
Other - Middle Name:B
Other - Last Name:SMITH
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:712 S KENYON CT
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-5902
Mailing Address - Country:US
Mailing Address - Phone:520-722-3396
Mailing Address - Fax:520-722-1147
Practice Address - Street 1:712 S KENYON CT
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-5902
Practice Address - Country:US
Practice Address - Phone:520-722-3396
Practice Address - Fax:520-722-1147
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4051385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child