Provider Demographics
NPI:1891934055
Name:SMITH, LORETTA
Entity Type:Individual
Prefix:
First Name:LORETTA
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 1:49 SFC 108
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:AR
Mailing Address - Zip Code:72372-9344
Mailing Address - Country:US
Mailing Address - Phone:870-581-2000
Mailing Address - Fax:
Practice Address - Street 1:51 N DUNLAP ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105
Practice Address - Country:US
Practice Address - Phone:901-287-5274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13932363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics