Healthcare Provider Details

I. General information

NPI: 1548827405
Provider Name (Legal Business Name): MRS. SONYA JEANEANNE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 BROADWAY ST APT J4
CLINTON MS
39056-4840
US

IV. Provider business mailing address

160 BROADWAY ST APT J4
CLINTON MS
39056-4840
US

V. Phone/Fax

Practice location:
  • Phone: 601-942-1467
  • Fax:
Mailing address:
  • Phone: 601-942-1467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number801040430
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: