Provider Demographics
NPI:1437617818
Name:SMITH, JOHNELLA
Entity Type:Individual
Prefix:
First Name:JOHNELLA
Middle Name:
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 1:7492 BRITTNAY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-8359
Mailing Address - Country:US
Mailing Address - Phone:901-922-9816
Mailing Address - Fax:
Practice Address - Street 1:7492 BRITTNAY DR
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-8359
Practice Address - Country:US
Practice Address - Phone:901-922-9816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide