Provider Demographics
NPI:1376126854
Name:SMITH, DEDRA L
Entity Type:Individual
Prefix:
First Name:DEDRA
Middle Name:L
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 1:1429 MONTANA AVE NE # M3
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-3427
Mailing Address - Country:US
Mailing Address - Phone:202-489-2566
Mailing Address - Fax:
Practice Address - Street 1:4638 HST SE
Practice Address - Street 2:206
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019
Practice Address - Country:US
Practice Address - Phone:202-621-8588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant