Provider Demographics
NPI:1497242374
Name:SMITH, TAMARA JANE
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:JANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:JANE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7571 TAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-9780
Mailing Address - Country:US
Mailing Address - Phone:567-277-6280
Mailing Address - Fax:
Practice Address - Street 1:7571 TAYSIDE DR
Practice Address - Street 2:
Practice Address - City:BLACKLICK
Practice Address - State:OH
Practice Address - Zip Code:43004-9780
Practice Address - Country:US
Practice Address - Phone:567-277-6280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH23111536164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse