Provider Demographics
NPI:1720365075
Name:SMITH, SHONTELLE (CNIM, REPT)
Entity Type:Individual
Prefix:
First Name:SHONTELLE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNIM, REPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:ANGLETON
Mailing Address - State:TX
Mailing Address - Zip Code:77515-4823
Mailing Address - Country:US
Mailing Address - Phone:832-298-6168
Mailing Address - Fax:
Practice Address - Street 1:617 HOLLY ST
Practice Address - Street 2:
Practice Address - City:ANGLETON
Practice Address - State:TX
Practice Address - Zip Code:77515-4823
Practice Address - Country:US
Practice Address - Phone:832-298-6168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic