Healthcare Provider Details

I. General information

NPI: 1639520307
Provider Name (Legal Business Name): QUIANA TIRZAH SMITH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 MONTAUK DR TLC HEALTH SOLUTIONS
GREENVILLE SC
29607-5069
US

IV. Provider business mailing address

212 MONTAUK DR AGAPE SENIOR PRIMARY CARE, INC., DBA TLC HEALTH SOLUTIO
GREENVILLE SC
29607-5069
US

V. Phone/Fax

Practice location:
  • Phone: 864-325-3981
  • Fax: 803-404-6000
Mailing address:
  • Phone: 864-325-3981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20271
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: