Provider Demographics
NPI:1437217197
Name:SMITH, MARLA LANE (PAC)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:LANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 KENDALL FARMS DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-9738
Mailing Address - Country:US
Mailing Address - Phone:615-293-0456
Mailing Address - Fax:
Practice Address - Street 1:107 NATCHEZ PARK DR
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-9013
Practice Address - Country:US
Practice Address - Phone:615-326-2960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1466363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical