Provider Demographics
NPI:1013296474
Name:SMITH, SYREETA DEVEANA (LPN)
Entity type:Individual
Prefix:
First Name:SYREETA
Middle Name:DEVEANA
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 RIVERSIDE ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14613-1235
Mailing Address - Country:US
Mailing Address - Phone:585-242-4853
Mailing Address - Fax:
Practice Address - Street 1:19 RIVERSIDE ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14613-1235
Practice Address - Country:US
Practice Address - Phone:585-242-4853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2022-08-26
Deactivation Date:2020-04-02
Deactivation Code:
Reactivation Date:2022-08-26
Provider Licenses
StateLicense IDTaxonomies
NY264710-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse