Healthcare Provider Details

I. General information

NPI: 1184302978
Provider Name (Legal Business Name): SHARA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

974 HAWTHORNE AVE E
SAINT PAUL MN
55106-2012
US

IV. Provider business mailing address

4835 PORTLAND AVE
MINNEAPOLIS MN
55417-1033
US

V. Phone/Fax

Practice location:
  • Phone: 651-247-3581
  • Fax:
Mailing address:
  • Phone: 651-247-3581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: