Provider Demographics
NPI:1407176316
Name:HODGE-SMITH, ROSLYN M
Entity Type:Individual
Prefix:
First Name:ROSLYN
Middle Name:M
Last Name:HODGE-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 1:25140 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:CALCIUM
Mailing Address - State:NY
Mailing Address - Zip Code:13616-2177
Mailing Address - Country:US
Mailing Address - Phone:315-629-6798
Mailing Address - Fax:
Practice Address - Street 1:21107 COFFEEN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-782-9285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY288268-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse