Provider Demographics
NPI:1700472487
Name:SMITH, DESTINY D
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:D
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:PO BOX 434
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:WV
Mailing Address - Zip Code:25984-0434
Mailing Address - Country:US
Mailing Address - Phone:304-237-8669
Mailing Address - Fax:
Practice Address - Street 1:9639 BLUE SULPHUR SPRINGS RD
Practice Address - Street 2:
Practice Address - City:ALDERSON
Practice Address - State:WV
Practice Address - Zip Code:24910-7260
Practice Address - Country:US
Practice Address - Phone:304-237-8669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant