Provider Demographics
NPI:1609575653
Name:SMITH, TYJA
Entity Type:Individual
Prefix:
First Name:TYJA
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 1:5623 GREGORY CT
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-1656
Mailing Address - Country:US
Mailing Address - Phone:804-888-0084
Mailing Address - Fax:
Practice Address - Street 1:5623 GREGORY CT
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-1656
Practice Address - Country:US
Practice Address - Phone:804-888-0084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA172V00000X
VA3801374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No172V00000XOther Service ProvidersCommunity Health Worker