Provider Demographics
NPI:1720200397
Name:SMITH, RUBY DIANE (PTA)
Entity Type:Individual
Prefix:MS
First Name:RUBY
Middle Name:DIANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:RUBY
Other - Middle Name:DIANE
Other - Last Name:SMITH HARRIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:95-1011 PUUKOA ST
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-6505
Mailing Address - Country:US
Mailing Address - Phone:863-409-5465
Mailing Address - Fax:
Practice Address - Street 1:95-1011 PUUKOA ST
Practice Address - Street 2:
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789-6505
Practice Address - Country:US
Practice Address - Phone:863-409-5465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 18427225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant