Provider Demographics
NPI:1184314205
Name:SMITH, RYLEA (CHW)
Entity type:Individual
Prefix:
First Name:RYLEA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:857 E MAIN ST STE 4
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:65793-1512
Mailing Address - Country:US
Mailing Address - Phone:417-469-7385
Mailing Address - Fax:417-469-7386
Practice Address - Street 1:857 E MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:WILLOW SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:65793-1512
Practice Address - Country:US
Practice Address - Phone:417-469-7385
Practice Address - Fax:417-469-7386
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019001937183700000X
MO15658172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No183700000XPharmacy Service ProvidersPharmacy Technician