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General NPI Number Information
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NPI Number | 1346745395
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Entity Type | Individual
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Provider Name | DIAMOND TYRELL-SMITH
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Gender | Female
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Dates
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Enumeration Date | 03/29/2018
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Last Update Date | 03/29/2018
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Provider Practice Location Address
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Address Line | 130 HARTFORD RD
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City | MANCHESTER
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State | CT
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Zip | 06040-5921
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Country | US
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Telephone | 860-538-8942
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Fax |
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Provider Business Mailing Address
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Address Line | 858 NEW BRITAIN AVE
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City | HARTFORD
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State | CT
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Zip | 06106-3919
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Country | US
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Telephone | 860-538-8942
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Fax |
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 048167788
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License Number State | CT
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