Provider Demographics
NPI:1598335911
Name:SMITH, JOHNELLE SHARNISE
Entity Type:Individual
Prefix:
First Name:JOHNELLE
Middle Name:SHARNISE
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 1:3365 N 53RD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-3260
Mailing Address - Country:US
Mailing Address - Phone:414-722-7304
Mailing Address - Fax:
Practice Address - Street 1:3365 N 53RD ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-3260
Practice Address - Country:US
Practice Address - Phone:414-722-7304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator