Healthcare Provider Details

I. General information

NPI: 1164837357
Provider Name (Legal Business Name): MISS PAULA TIFFANY NICOLE SMALLWOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PAULA TIFFANY NICOLE STINNETT

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 09/21/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 HILLVIEW DR
LEITCHFIELD KY
42754-1807
US

IV. Provider business mailing address

109 HILLVIEW DR
LEITCHFIELD KY
42754-1807
US

V. Phone/Fax

Practice location:
  • Phone: 270-899-0175
  • Fax:
Mailing address:
  • Phone: 270-899-0175
  • Fax: 844-688-4227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number201154945
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: