Provider Demographics
NPI:1467120824
Name:SMITH, NICCHOE N
Entity Type:Individual
Prefix:
First Name:NICCHOE
Middle Name:N
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 1:4300 RIVER WATCH PKWY APT 702
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-3861
Mailing Address - Country:US
Mailing Address - Phone:706-951-5475
Mailing Address - Fax:
Practice Address - Street 1:4300 RIVER WATCH PKWY APT 702
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-3861
Practice Address - Country:US
Practice Address - Phone:706-951-5475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2022-02-10
Deactivation Date:2021-09-01
Deactivation Code:
Reactivation Date:2022-02-10
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy