Provider Demographics
NPI:1639123664
Name:SMITH, NANCY J (CCCA MSA)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:CCCA MSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRAND SALINE
Mailing Address - State:TX
Mailing Address - Zip Code:75140-1846
Mailing Address - Country:US
Mailing Address - Phone:903-203-5252
Mailing Address - Fax:
Practice Address - Street 1:208 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GRAND SALINE
Practice Address - State:TX
Practice Address - Zip Code:75140-1846
Practice Address - Country:US
Practice Address - Phone:903-203-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51506231H00000X
TX91078237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F3243Medicare PIN