Healthcare Provider Details

I. General information

NPI: 1477479251
Provider Name (Legal Business Name): TAMARA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10687 AUTO MALL PKWY
DIBERVILLE MS
39540-3755
US

IV. Provider business mailing address

10687 AUTO MALL PKWY APT 228
DIBERVILLE MS
39540-3774
US

V. Phone/Fax

Practice location:
  • Phone: 228-355-6135
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License Number802117167
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: