Provider Demographics
NPI:1497164917
Name:SMITH, TYRA
Entity Type:Individual
Prefix:
First Name:TYRA
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 1:3012 CARSKADDON AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-6608
Mailing Address - Country:US
Mailing Address - Phone:419-932-5318
Mailing Address - Fax:
Practice Address - Street 1:3012 CARSKADDON AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-6607
Practice Address - Country:US
Practice Address - Phone:419-932-5318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-08
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH103557194099Medicaid
OH0092134OtherPROVIDER NUMBER