Healthcare Provider Details

I. General information

NPI: 1952071151
Provider Name (Legal Business Name): NIAH SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 BRENTWOOD RD
BAY SHORE NY
11706-5705
US

IV. Provider business mailing address

1314 BRENTWOOD RD
BAY SHORE NY
11706-5705
US

V. Phone/Fax

Practice location:
  • Phone: 631-308-8252
  • Fax:
Mailing address:
  • Phone: 631-308-8252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number330524-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: