Provider Demographics
NPI:1265189260
Name:SMITH-WALLER, VENNETTA M
Entity type:Individual
Prefix:
First Name:VENNETTA
Middle Name:M
Last Name:SMITH-WALLER
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 1:21270 CAROL DR
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44119-1829
Mailing Address - Country:US
Mailing Address - Phone:216-973-7383
Mailing Address - Fax:216-291-7684
Practice Address - Street 1:21270 CAROL DR
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44119-1829
Practice Address - Country:US
Practice Address - Phone:216-973-7383
Practice Address - Fax:216-291-7684
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRK885070343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)