Provider Demographics
NPI:1851070460
Name:SMITH, THOMAS L (LPN, LMT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPN, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 S JOSEPHINE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSALIA
Mailing Address - State:WA
Mailing Address - Zip Code:99170-9570
Mailing Address - Country:US
Mailing Address - Phone:503-307-1886
Mailing Address - Fax:
Practice Address - Street 1:315 S JOSEPHINE AVE
Practice Address - Street 2:
Practice Address - City:ROSALIA
Practice Address - State:WA
Practice Address - Zip Code:99170-9570
Practice Address - Country:US
Practice Address - Phone:503-307-1886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP60202622164W00000X
WAMA00009284225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist