Provider Demographics
NPI:1467847087
Name:SMITH, BALLARD LANDER
Entity Type:Individual
Prefix:
First Name:BALLARD
Middle Name:LANDER
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 1:24 BOARDWALK
Mailing Address - Street 2:
Mailing Address - City:PIKE ROAD
Mailing Address - State:AL
Mailing Address - Zip Code:36064-3837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 BOARDWALK
Practice Address - Street 2:
Practice Address - City:PIKE ROAD
Practice Address - State:AL
Practice Address - Zip Code:36064-3837
Practice Address - Country:US
Practice Address - Phone:334-590-4072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS10769390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program