Provider Demographics
NPI:1629444641
Name:SMITH, ELLENA
Entity Type:Individual
Prefix:
First Name:ELLENA
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 1:3715 KADEY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-2290
Mailing Address - Country:US
Mailing Address - Phone:301-640-0151
Mailing Address - Fax:
Practice Address - Street 1:3715 KADEY DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-2290
Practice Address - Country:US
Practice Address - Phone:301-640-0151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-13
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No374U00000XNursing Service Related ProvidersHome Health Aide
No372600000XNursing Service Related ProvidersAdult Companion
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374700000XNursing Service Related ProvidersTechnician