Provider Demographics
NPI:1538478698
Name:SMITH, CARRISSA M (TM, FSD)
Entity Type:Individual
Prefix:MRS
First Name:CARRISSA
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:TM, FSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 N MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721-5129
Mailing Address - Country:US
Mailing Address - Phone:435-574-4226
Mailing Address - Fax:
Practice Address - Street 1:736 N MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84721-5129
Practice Address - Country:US
Practice Address - Phone:435-574-4226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-06
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT374J00000X
175M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175M00000XOther Service ProvidersMidwife, Lay
No374J00000XNursing Service Related ProvidersDoula