Healthcare Provider Details

I. General information

NPI: 1285608703
Provider Name (Legal Business Name): TARA SHANNON SMITH C.N.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26005 RIDGE RD SUITE 200
DAMASCUS MD
20872-1892
US

IV. Provider business mailing address

26005 RIDGE RD SUITE 200
DAMASCUS MD
20872-1892
US

V. Phone/Fax

Practice location:
  • Phone: 301-414-2300
  • Fax: 301-414-2306
Mailing address:
  • Phone: 301-414-2300
  • Fax: 301-414-2306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number0024165986
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001146963
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAC00911
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: