Healthcare Provider Details

I. General information

NPI: 1891934055
Provider Name (Legal Business Name): LORETTA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 N DUNLAP ST
MEMPHIS TN
38105
US

IV. Provider business mailing address

49 SFC 108
PALESTINE AR
72372-9344
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-5274
  • Fax:
Mailing address:
  • Phone: 870-581-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number13932
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: