Provider Demographics
NPI:1932414216
Name:SMITH, PENELOPE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:PENELOPE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 MORRIS SONES RD
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-6627
Mailing Address - Country:US
Mailing Address - Phone:601-862-0670
Mailing Address - Fax:
Practice Address - Street 1:2322 HIGHWAY 43 S
Practice Address - Street 2:SUITE A
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-7525
Practice Address - Country:US
Practice Address - Phone:601-799-4118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS811225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist