Provider Demographics
NPI:1740888049
Name:SMITH, CONNIE S
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:S
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 1631
Mailing Address - Street 2:
Mailing Address - City:HINTON
Mailing Address - State:WV
Mailing Address - Zip Code:25951-1631
Mailing Address - Country:US
Mailing Address - Phone:304-923-3697
Mailing Address - Fax:
Practice Address - Street 1:638 TUG CREEK MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:HINTON
Practice Address - State:WV
Practice Address - Zip Code:25951-5706
Practice Address - Country:US
Practice Address - Phone:304-923-3697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant