Provider Demographics
NPI:1457870503
Name:SMITH, ABIGAIL ALEXA
Entity type:Individual
Prefix:MS
First Name:ABIGAIL
Middle Name:ALEXA
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 1:371 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18705-2425
Mailing Address - Country:US
Mailing Address - Phone:603-913-4278
Mailing Address - Fax:
Practice Address - Street 1:371 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18705-2425
Practice Address - Country:US
Practice Address - Phone:603-913-4278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-10
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
PA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer