Provider Demographics
NPI:1790379196
Name:SMITH, SHARON ELAINE
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:ELAINE
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 1:755 E WHITTIER ST APT 104
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-2991
Mailing Address - Country:US
Mailing Address - Phone:614-900-9608
Mailing Address - Fax:
Practice Address - Street 1:755 E WHITTIER ST APT 104
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43206-2991
Practice Address - Country:US
Practice Address - Phone:614-900-9608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0350742Medicaid