Provider Demographics
NPI:1912788613
Name:TY SMITH NURSE PRACTITIONER ADULT
Entity Type:Organization
Organization Name:TY SMITH NURSE PRACTITIONER ADULT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-284-7521
Mailing Address - Street 1:1595 N CENTRAL AVE APT 39
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1186
Mailing Address - Country:US
Mailing Address - Phone:516-770-6102
Mailing Address - Fax:
Practice Address - Street 1:76 S CENTRAL AVE STE 1A
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-5405
Practice Address - Country:US
Practice Address - Phone:516-770-6102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-09
Last Update Date:2024-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service