=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588162341
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GENQUETTA MICHELLE SMITH INDEPENDE CONTRACTOR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2018
-----------------------------------------------------
Last Update Date | 01/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7938 CARRIAGE POINTE DR
-----------------------------------------------------
City | GIBSONTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33534-3007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-657-8044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 418
-----------------------------------------------------
City | SEFFNER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33583-0418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-657-8044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2470A2800X
-----------------------------------------------------
Taxonomy Name | Assistant Health Information Record Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2472R0900X
-----------------------------------------------------
Taxonomy Name | Renal Dialysis Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 372600000X
-----------------------------------------------------
Taxonomy Name | Adult Companion
-----------------------------------------------------
License Number | 131219
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | 1311219
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number | 131219
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------