Provider Demographics
NPI:1407503618
Name:SMITH, TINA MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-1501
Mailing Address - Country:US
Mailing Address - Phone:419-419-5705
Mailing Address - Fax:419-775-1254
Practice Address - Street 1:475 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-1501
Practice Address - Country:US
Practice Address - Phone:419-419-5705
Practice Address - Fax:419-775-1254
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH092041164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse