Provider Demographics
NPI:1821319559
Name:SMITH, REGINA CHANELLE (RN)
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:CHANELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2580 W CAMP WISDOM RD
Mailing Address - Street 2:SUITE, 100 - #137
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-3088
Mailing Address - Country:US
Mailing Address - Phone:972-606-4908
Mailing Address - Fax:
Practice Address - Street 1:2846 ALCOTT LN
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-8345
Practice Address - Country:US
Practice Address - Phone:972-606-4908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX578436171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator