Provider Demographics
NPI:1407968530
Name:SMITH, TAMARA JENEAN (FNP)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:JENEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 BRUNSON DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4947
Mailing Address - Country:US
Mailing Address - Phone:662-680-3855
Mailing Address - Fax:662-680-3372
Practice Address - Street 1:602 BRUNSON DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4947
Practice Address - Country:US
Practice Address - Phone:662-680-3855
Practice Address - Fax:662-680-3372
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR587702363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113839Medicaid
MS00113839Medicaid