Provider Demographics
NPI:1134958259
Name:SMITH, MISTY DAWN (CNA)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:DAWN
Other - Last Name:CHILDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA
Mailing Address - Street 1:732 N CHANDLER DR APT 3204
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-4250
Mailing Address - Country:US
Mailing Address - Phone:817-995-1290
Mailing Address - Fax:
Practice Address - Street 1:719 BLYTH RD
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2769
Practice Address - Country:US
Practice Address - Phone:817-995-1290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide