Provider Demographics
NPI:1598930984
Name:SMITH, PATRICIA ANN
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
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 1:200 RIDGE MANOR DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-5014
Mailing Address - Country:US
Mailing Address - Phone:863-676-2144
Mailing Address - Fax:863-676-2144
Practice Address - Street 1:200 RIDGE MANOR DR
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-5014
Practice Address - Country:US
Practice Address - Phone:863-676-2144
Practice Address - Fax:863-676-2144
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency