Provider Demographics
NPI:1508372897
Name:SMITH, LAVON LASHANDA (BSN, RN)
Entity Type:Individual
Prefix:
First Name:LAVON
Middle Name:LASHANDA
Last Name:SMITH
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:LAVON
Other - Middle Name:LASHANDA
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:115 S CEDAR AVE # LEVEL1
Mailing Address - Street 2:
Mailing Address - City:MAPLE SHADE
Mailing Address - State:NJ
Mailing Address - Zip Code:08052-1711
Mailing Address - Country:US
Mailing Address - Phone:856-571-3312
Mailing Address - Fax:
Practice Address - Street 1:115 S CEDAR AVE
Practice Address - Street 2:
Practice Address - City:MAPLE SHADE
Practice Address - State:NJ
Practice Address - Zip Code:08052-1711
Practice Address - Country:US
Practice Address - Phone:856-571-3312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN681687163W00000X
NJ26NR18139900163W00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1508372897Medicaid