Provider Demographics
NPI:1629559596
Name:SMITH, ROSANETTA
Entity Type:Individual
Prefix:
First Name:ROSANETTA
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 1:1104 FERGUSON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-5391
Mailing Address - Country:US
Mailing Address - Phone:702-553-8139
Mailing Address - Fax:702-553-8139
Practice Address - Street 1:1104 FERGUSON AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-5391
Practice Address - Country:US
Practice Address - Phone:702-553-8139
Practice Address - Fax:702-553-8139
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20181306317251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health