Healthcare Provider Details

I. General information

NPI: 1730447855
Provider Name (Legal Business Name): LATESE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 SMITH RD
NEWPORT RI
02841-1006
US

IV. Provider business mailing address

36 ELLIOT ST
NEWPORT RI
02841-1505
US

V. Phone/Fax

Practice location:
  • Phone: 401-841-3771
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: