Provider Demographics
NPI:1700216413
Name:SMITH, REESA (LPN)
Entity Type:Individual
Prefix:
First Name:REESA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 RANDOLPH RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:NC
Mailing Address - Zip Code:28034-9630
Mailing Address - Country:US
Mailing Address - Phone:704-813-5723
Mailing Address - Fax:
Practice Address - Street 1:991 W HUDSON BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-6430
Practice Address - Country:US
Practice Address - Phone:704-853-5464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC77642164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse