Healthcare Provider Details

I. General information

NPI: 1598416547
Provider Name (Legal Business Name): TIFFANY MONIQUE SMITH PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2006 BREMO RD STE 101
RICHMOND VA
23226-2438
US

IV. Provider business mailing address

2006 BREMO RD STE 101
RICHMOND VA
23226-2438
US

V. Phone/Fax

Practice location:
  • Phone: 804-288-1881
  • Fax:
Mailing address:
  • Phone: 804-288-1881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024183177
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: