Provider Demographics
NPI:1316591894
Name:SMITH, MORIETTA
Entity Type:Individual
Prefix:
First Name:MORIETTA
Middle Name:
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 1:605 OLD SAVANNAH DR
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-9600
Mailing Address - Country:US
Mailing Address - Phone:228-383-4448
Mailing Address - Fax:
Practice Address - Street 1:605 OLD SAVANNAH DR
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-9600
Practice Address - Country:US
Practice Address - Phone:228-383-4448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider