Healthcare Provider Details

I. General information

NPI: 1861690315
Provider Name (Legal Business Name): VICTORIA RENERA-NISA SMITH DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VICTORIA LAMB

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DUKE UNIVERSITY HEALTH SYSTEM 4020 NORTH ROXBORO ST
DURHAM NC
27704
US

IV. Provider business mailing address

1102 CELANDINE DR
APEX NC
27502-4164
US

V. Phone/Fax

Practice location:
  • Phone: 919-613-1720
  • Fax:
Mailing address:
  • Phone: 919-208-0518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number11179
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11179
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: