Healthcare Provider Details

I. General information

NPI: 1922751122
Provider Name (Legal Business Name): KHANDICE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2022
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E JACKSON ST STE 3300
TAMPA FL
33602-5228
US

IV. Provider business mailing address

PO BOX 320116
TAMPA FL
33679-2116
US

V. Phone/Fax

Practice location:
  • Phone: 470-471-9297
  • Fax:
Mailing address:
  • Phone: 470-471-9297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: