Healthcare Provider Details

I. General information

NPI: 1811460876
Provider Name (Legal Business Name): MAKESHIA SMITH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2019
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3640 W WACO DR
WACO TX
76710-5345
US

IV. Provider business mailing address

25 ADDIE LN
WACO TX
76705-1046
US

V. Phone/Fax

Practice location:
  • Phone: 254-307-8607
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number822311
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: