Provider Demographics
NPI:1134956766
Name:SMITH, SIERRA BROOKE
Entity type:Individual
Prefix:
First Name:SIERRA
Middle Name:BROOKE
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 1:110 MALLARD DR
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-2014
Mailing Address - Country:US
Mailing Address - Phone:315-727-3451
Mailing Address - Fax:
Practice Address - Street 1:159 CROSSOVER RD
Practice Address - Street 2:
Practice Address - City:BEULAVILLE
Practice Address - State:NC
Practice Address - Zip Code:28518-8801
Practice Address - Country:US
Practice Address - Phone:910-298-6455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052883225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist