Provider Demographics
NPI:1477105039
Name:SMITH, TAWANNA L
Entity Type:Individual
Prefix:
First Name:TAWANNA
Middle Name:L
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 1:20618 MOUNTILLE DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-1095
Mailing Address - Country:US
Mailing Address - Phone:216-224-6478
Mailing Address - Fax:888-460-4717
Practice Address - Street 1:20618 MOUNTILLE DR
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-1095
Practice Address - Country:US
Practice Address - Phone:216-224-6478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-14
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide