Provider Demographics
NPI:1598416661
Name:SMITH, TIZITA
Entity Type:Individual
Prefix:
First Name:TIZITA
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 1:915 S BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4027
Mailing Address - Country:US
Mailing Address - Phone:660-956-9156
Mailing Address - Fax:660-956-9151
Practice Address - Street 1:915 S BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4027
Practice Address - Country:US
Practice Address - Phone:660-956-9156
Practice Address - Fax:660-956-9151
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021045038237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1710498019OtherHEARKEN HEARING & AUDIOLOGY