Healthcare Provider Details

I. General information

NPI: 1740870708
Provider Name (Legal Business Name): SHAQUITA LASHAY SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2021
Last Update Date: 01/24/2021
Certification Date: 01/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6621 MEADOWLARK LN APT B
LITTLE ROCK AR
72209-2767
US

IV. Provider business mailing address

6621 MEADOWLARK LN APT B
LITTLE ROCK AR
72209-2767
US

V. Phone/Fax

Practice location:
  • Phone: 501-786-6765
  • Fax:
Mailing address:
  • Phone: 501-786-6765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number151414
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: