=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174296313
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CALLY MICHELLE SMITH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2021
-----------------------------------------------------
Last Update Date | 11/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3124 S 19TH ST STE 220
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98405-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-301-5050
-----------------------------------------------------
Fax | 253-301-5070
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2715 40TH ST E APT D
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98404-5335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-686-5434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA61350382
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------