Provider Demographics
NPI:1831336445
Name:SMITH, TEDRA SIMMONS (DNP)
Entity type:Individual
Prefix:
First Name:TEDRA
Middle Name:SIMMONS
Last Name:SMITH
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:TEDRA
Other - Middle Name:LARAGAN
Other - Last Name:SIMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:1600 7TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1711
Mailing Address - Country:US
Mailing Address - Phone:205-939-5724
Mailing Address - Fax:
Practice Address - Street 1:1600 7TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1711
Practice Address - Country:US
Practice Address - Phone:205-939-5724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-095332363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics