Provider Demographics
NPI:1346540630
Name:SMITH SHILLINGFORD, LUCILLE
Entity Type:Individual
Prefix:MRS
First Name:LUCILLE
Middle Name:
Last Name:SMITH SHILLINGFORD
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 1:2004 DARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-5718
Mailing Address - Country:US
Mailing Address - Phone:813-417-1352
Mailing Address - Fax:813-665-4394
Practice Address - Street 1:2004 DARLINGTON DR.
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-5718
Practice Address - Country:US
Practice Address - Phone:813-417-1352
Practice Address - Fax:813-665-4394
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL677683398Medicaid
FL677683396Medicaid