Provider Demographics
NPI:1992265805
Name:SMITH, MISTY DAWN
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
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 1:524 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38556-3247
Mailing Address - Country:US
Mailing Address - Phone:931-267-8784
Mailing Address - Fax:
Practice Address - Street 1:342 W CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:TN
Practice Address - Zip Code:38556
Practice Address - Country:US
Practice Address - Phone:931-879-9073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4092235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist