Healthcare Provider Details

I. General information

NPI: 1982166393
Provider Name (Legal Business Name): TYRA PAIGE REECE-SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N FRESNO ST
FRESNO CA
93701-2302
US

IV. Provider business mailing address

2880 ATLANTIC AVE STE 170
LONG BEACH CA
90806-1715
US

V. Phone/Fax

Practice location:
  • Phone: 559-499-6556
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA177468
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: