Healthcare Provider Details

I. General information

NPI: 1033054648
Provider Name (Legal Business Name): TAMARA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10221 SURF DR
SAINT LOUIS MO
63137-1568
US

IV. Provider business mailing address

10221 SURF DR
SAINT LOUIS MO
63137-1568
US

V. Phone/Fax

Practice location:
  • Phone: 557-203-8652
  • Fax:
Mailing address:
  • Phone: 557-203-8652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: