Healthcare Provider Details

I. General information

NPI: 1770282063
Provider Name (Legal Business Name): KEYANNA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 02/27/2023
Certification Date: 02/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7020 CLAREMORE DR
SAINT LOUIS MO
63121-5204
US

IV. Provider business mailing address

7020 CLAREMORE DR
SAINT LOUIS MO
63121-5204
US

V. Phone/Fax

Practice location:
  • Phone: 314-457-3234
  • Fax:
Mailing address:
  • Phone: 314-457-3234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: