Provider Demographics
NPI:1992357966
Name:SMITH, STEPHANIE JANAE (PTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JANAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 PERRYS TOWN RD
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:KY
Mailing Address - Zip Code:41817-9100
Mailing Address - Country:US
Mailing Address - Phone:606-634-1765
Mailing Address - Fax:
Practice Address - Street 1:11203 MAIN ST
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:KY
Practice Address - Zip Code:41649-7999
Practice Address - Country:US
Practice Address - Phone:606-285-6670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02406225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant