Provider Demographics
NPI:1891400305
Name:SMITH, TAKIESHA
Entity Type:Individual
Prefix:MRS
First Name:TAKIESHA
Middle Name:
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 1:10341 CRESTRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9097
Mailing Address - Country:US
Mailing Address - Phone:317-537-7930
Mailing Address - Fax:
Practice Address - Street 1:10341 CRESTRIDGE CT
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9097
Practice Address - Country:US
Practice Address - Phone:317-537-7930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN14664374J00000X
IN342954174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula