Provider Demographics
NPI:1477293777
Name:SMITH, CHARLA JENEA (PT)
Entity Type:Individual
Prefix:MRS
First Name:CHARLA JENEA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CHARLA
Other - Middle Name:JENEA
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:711 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-2903
Mailing Address - Country:US
Mailing Address - Phone:573-582-8888
Mailing Address - Fax:573-582-3774
Practice Address - Street 1:711 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-2903
Practice Address - Country:US
Practice Address - Phone:573-582-8888
Practice Address - Fax:573-582-3774
Is Sole Proprietor?:No
Enumeration Date:2022-04-01
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999137421225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist