Provider Demographics
NPI:1265720676
Name:SMITH, DIANE FELTON (TRANPORTATION)
Entity type:Individual
Prefix:MISS
First Name:DIANE
Middle Name:FELTON
Last Name:SMITH
Suffix:
Gender:F
Credentials:TRANPORTATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 N LAKE DR
Mailing Address - Street 2:APT.601
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-1691
Mailing Address - Country:US
Mailing Address - Phone:478-287-8461
Mailing Address - Fax:
Practice Address - Street 1:206 N LAKE DR
Practice Address - Street 2:APT.601
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-1691
Practice Address - Country:US
Practice Address - Phone:478-287-8461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049358798347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle