Provider Demographics
NPI:1568932457
Name:SMYLES, NAKEISHA N
Entity Type:Individual
Prefix:
First Name:NAKEISHA
Middle Name:N
Last Name:SMYLES
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 1:1930 PARK WEST BLVD APT 1D
Mailing Address - Street 2:
Mailing Address - City:GRIFFITH
Mailing Address - State:IN
Mailing Address - Zip Code:46319-1239
Mailing Address - Country:US
Mailing Address - Phone:708-916-4246
Mailing Address - Fax:
Practice Address - Street 1:8419 S COTTAGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-6113
Practice Address - Country:US
Practice Address - Phone:773-651-0200
Practice Address - Fax:773-651-8968
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILXOG901421935Medicaid