Provider Demographics
NPI:1417623901
Name:SMITH, SADIE ELIZABETH
Entity Type:Individual
Prefix:
First Name:SADIE
Middle Name:ELIZABETH
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 1:960 COUNTY ROAD 4700
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75494-6479
Mailing Address - Country:US
Mailing Address - Phone:903-975-0683
Mailing Address - Fax:
Practice Address - Street 1:3900 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75799-6600
Practice Address - Country:US
Practice Address - Phone:903-565-5777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program