Provider Demographics
NPI:1437913449
Name:SMITH, TERESA JILLIAN
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:JILLIAN
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 1:5221 TANGO LN
Mailing Address - Street 2:
Mailing Address - City:ELLISTON
Mailing Address - State:VA
Mailing Address - Zip Code:24087-3415
Mailing Address - Country:US
Mailing Address - Phone:540-588-0236
Mailing Address - Fax:
Practice Address - Street 1:2100 ROANOKE ST # 1
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-2512
Practice Address - Country:US
Practice Address - Phone:833-522-0556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002078827164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse