Provider Demographics
NPI:1477179422
Name:SMITH, BIANCA
Entity Type:Individual
Prefix:
First Name:BIANCA
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 1:1030 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2127
Mailing Address - Country:US
Mailing Address - Phone:901-523-8990
Mailing Address - Fax:
Practice Address - Street 1:136 PECAN ST
Practice Address - Street 2:
Practice Address - City:MARKED TREE
Practice Address - State:AR
Practice Address - Zip Code:72365-1926
Practice Address - Country:US
Practice Address - Phone:870-375-0603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider