Healthcare Provider Details

I. General information

NPI: 1639123664
Provider Name (Legal Business Name): NANCY J SMITH CCCA MSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 N MAIN ST
GRAND SALINE TX
75140-1846
US

IV. Provider business mailing address

208 N MAIN ST
GRAND SALINE TX
75140-1846
US

V. Phone/Fax

Practice location:
  • Phone: 903-203-5252
  • Fax:
Mailing address:
  • Phone: 903-203-5252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number51506
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number91078
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: