Provider Demographics
NPI:1023283199
Name:CROSS- SMOTHERS, TINA M
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:M
Last Name:CROSS- SMOTHERS
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 1:110 CLARENDON AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-4623
Mailing Address - Country:US
Mailing Address - Phone:330-455-1352
Mailing Address - Fax:
Practice Address - Street 1:110 CLARENDON AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-4623
Practice Address - Country:US
Practice Address - Phone:330-455-1352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRL532515172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver