Healthcare Provider Details

I. General information

NPI: 1629565536
Provider Name (Legal Business Name): TINA KAYZELLERS SMITH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 TIMBER CREEK DR STE 200
CORDOVA TN
38018
US

IV. Provider business mailing address

2606 MEADOW RUN
GERMANTOWN TN
38138-6254
US

V. Phone/Fax

Practice location:
  • Phone: 901-751-4112
  • Fax: 901-751-9878
Mailing address:
  • Phone: 901-361-5886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number23820
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier220366
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerRN
# 2
Identifier23820
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerAPN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: