Healthcare Provider Details

I. General information

NPI: 1467193995
Provider Name (Legal Business Name): GWONDA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 EDEN WAY N SUITE H
CHESAPEAKE VA
23320
US

IV. Provider business mailing address

732 EDEN WAY N SUITE H 1202 WELLES CT
CHESAPEAKE VA
23320
US

V. Phone/Fax

Practice location:
  • Phone: 757-716-1273
  • Fax:
Mailing address:
  • Phone: 757-716-1273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number103514
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: