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General NPI Number Information
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NPI Number | 1104060631
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Entity Type | Individual
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Provider Name | MS. RENITA G SMITH
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Gender | Female
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Dates
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Enumeration Date | 04/28/2009
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Last Update Date | 04/28/2009
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Provider Practice Location Address
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Address Line | 4044 W LAKE MARY BLVD 257
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City | LAKE MARY
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State | FL
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Zip | 32746-2012
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Country | US
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Telephone | 585-303-6776
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Fax | 321-206-8760
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Provider Business Mailing Address
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Address Line | 4044 W LAKE MARY BLVD 257
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City | LAKE MARY
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State | FL
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Zip | 32746-2012
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Country | US
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Telephone | 585-303-6776
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Fax | 321-206-8760
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2472E0500X
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Taxonomy Name | EEG Technician
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License Number | 641116070073
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License Number State | FL
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