Healthcare Provider Details

I. General information

NPI: 1710011994
Provider Name (Legal Business Name): SANDRA LYNNETTE SMITH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HWY 78 S,
TIPTONVILLE TN
38079
US

IV. Provider business mailing address

400 HWY 78 S.
TIPTONVILLE TN
38079
US

V. Phone/Fax

Practice location:
  • Phone: 731-253-9954
  • Fax:
Mailing address:
  • Phone: 731-253-9954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN0000062482
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: