Provider Demographics
NPI:1467193995
Name:SMITH, GWONDA
Entity Type:Individual
Prefix:
First Name:GWONDA
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 1:732 EDEN WAY N SUITE H
Mailing Address - Street 2:1202 WELLES CT
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320
Mailing Address - Country:US
Mailing Address - Phone:757-716-1273
Mailing Address - Fax:
Practice Address - Street 1:732 EDEN WAY N SUITE H
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320
Practice Address - Country:US
Practice Address - Phone:757-716-1273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1035141744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management