Provider Demographics
NPI:1932886173
Name:SMITH, FALLEN (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:FALLEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18425 WESTPHALIA ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205-2642
Mailing Address - Country:US
Mailing Address - Phone:313-399-6158
Mailing Address - Fax:
Practice Address - Street 1:18425 WESTPHALIA ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-2642
Practice Address - Country:US
Practice Address - Phone:313-399-6158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704390485163W00000X
MI470390485163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse