Provider Demographics
NPI:1629565536
Name:SMITH, TINA KAYZELLERS (NP)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:KAYZELLERS
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2606 MEADOW RUN
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-6254
Mailing Address - Country:US
Mailing Address - Phone:901-361-5886
Mailing Address - Fax:
Practice Address - Street 1:146 TIMBER CREEK DR STE 200
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018
Practice Address - Country:US
Practice Address - Phone:901-751-4112
Practice Address - Fax:901-751-9878
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23820363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN220366OtherRN
TN23820OtherAPN