Provider Demographics
NPI:1780183434
Name:SMITH, TIANNA L
Entity Type:Individual
Prefix:
First Name:TIANNA
Middle Name:L
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 1:8204 GRAVOIS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-4725
Mailing Address - Country:US
Mailing Address - Phone:314-405-1114
Mailing Address - Fax:
Practice Address - Street 1:439 FASSEN ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63111-1912
Practice Address - Country:US
Practice Address - Phone:314-484-1846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOX137003006347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle