Provider Demographics
NPI:1821534298
Name:SMITH, DANITA (RN)
Entity Type:Individual
Prefix:
First Name:DANITA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2040 WOODSON RD STE 204A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63114-5697
Mailing Address - Country:US
Mailing Address - Phone:314-942-3272
Mailing Address - Fax:314-584-2205
Practice Address - Street 1:224 N HIGHWAY 67 ST
Practice Address - Street 2:SUITE 252
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-5904
Practice Address - Country:US
Practice Address - Phone:314-942-3272
Practice Address - Fax:314-584-2205
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO291U00000X
MO152662163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1080096Medicaid