Provider Demographics
NPI:1881357812
Name:SMITH, CONNIE L
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
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 1:1930 CLUB POND RD STE 107
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-8691
Mailing Address - Country:US
Mailing Address - Phone:910-299-6226
Mailing Address - Fax:
Practice Address - Street 1:112 EULON LOOP APT A
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-9674
Practice Address - Country:US
Practice Address - Phone:910-299-6226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-17
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No385H00000XRespite Care FacilityRespite Care
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child