Provider Demographics
NPI:1528373149
Name:SMITH, NITA
Entity Type:Individual
Prefix:MS
First Name:NITA
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 1:563 HOWDERSHELL RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-6401
Mailing Address - Country:US
Mailing Address - Phone:314-921-9448
Mailing Address - Fax:314-921-9440
Practice Address - Street 1:563 HOWDERSHELL RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-6401
Practice Address - Country:US
Practice Address - Phone:314-921-9448
Practice Address - Fax:314-921-9440
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-09
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372500000X, 3747P1801X
MO0007914251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No372500000XNursing Service Related ProvidersChore Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO273564356Medicaid