Healthcare Provider Details

I. General information

NPI: 1275718660
Provider Name (Legal Business Name): JOHNATHON CRAWFORD SMITH SR. CLPN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 BANKHEAD RD SW
MANTACHIE MS
38855-7267
US

IV. Provider business mailing address

165 BANKHEAD ROAD
MANTACHIE MS
38855-7265
US

V. Phone/Fax

Practice location:
  • Phone: 662-840-1944
  • Fax:
Mailing address:
  • Phone: 662-840-1944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberP231371
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: