Healthcare Provider Details

I. General information

NPI: 1841894193
Provider Name (Legal Business Name): PHYLLIS SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2020
Last Update Date: 11/27/2020
Certification Date: 11/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4685 PANHANDLE RD
NEW VIENNA OH
45159-9415
US

IV. Provider business mailing address

4685 PANHANDLE RD
NEW VIENNA OH
45159-9415
US

V. Phone/Fax

Practice location:
  • Phone: 937-728-9589
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: