Provider Demographics
NPI:1689195331
Name:SMITH, TONYA MICHELLE
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:MICHELLE
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 1:5915 HIL MAR DR
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20747-2976
Mailing Address - Country:US
Mailing Address - Phone:301-516-3367
Mailing Address - Fax:
Practice Address - Street 1:1040 SOUTHERN AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-6042
Practice Address - Country:US
Practice Address - Phone:202-563-1353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-03
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA70787256Medicaid