Provider Demographics
NPI:1942549241
Name:SMITH, JOLETTA A
Entity Type:Individual
Prefix:
First Name:JOLETTA
Middle Name:A
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 1:4161 TAMIAMI TRL STE 704
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-9283
Mailing Address - Country:US
Mailing Address - Phone:941-625-1110
Mailing Address - Fax:941-625-0552
Practice Address - Street 1:4161 TAMIAMI TRL STE 704
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-9283
Practice Address - Country:US
Practice Address - Phone:941-625-1110
Practice Address - Fax:941-625-0552
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PTAT23898171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor