Provider Demographics
NPI:1700568250
Name:SMOOT-RICHARDSON, SALETHA SHARON
Entity Type:Individual
Prefix:
First Name:SALETHA
Middle Name:SHARON
Last Name:SMOOT-RICHARDSON
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 1:20 PUBLIX DR # 104-114
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-9362
Mailing Address - Country:US
Mailing Address - Phone:252-710-6339
Mailing Address - Fax:
Practice Address - Street 1:87 ROSE PETAL CT
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597-9495
Practice Address - Country:US
Practice Address - Phone:252-710-6339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000029485065343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)