Provider Demographics
NPI:1437811569
Name:SMITH, SHALITA
Entity Type:Individual
Prefix:
First Name:SHALITA
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 1:4806 MANTLEWOOD WAY APT 102
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MD
Mailing Address - Zip Code:21001-3646
Mailing Address - Country:US
Mailing Address - Phone:443-739-2084
Mailing Address - Fax:410-238-7463
Practice Address - Street 1:100 S TAYLOR AVE.
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:MD
Practice Address - Zip Code:21221
Practice Address - Country:US
Practice Address - Phone:443-739-2084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03-050261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2188G72MOtherMEDICAL ASSISTANCE/MEDICARE/MEDICAID/PRIVATE