Provider Demographics
NPI:1831653278
Name:SMITH, KEDRA LATRICE
Entity Type:Individual
Prefix:
First Name:KEDRA
Middle Name:LATRICE
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 1:3180 CONVENTION ST
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-3711
Mailing Address - Country:US
Mailing Address - Phone:225-936-9601
Mailing Address - Fax:
Practice Address - Street 1:3180 CONVENTION ST
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-3711
Practice Address - Country:US
Practice Address - Phone:225-936-9601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1215474275Medicaid