=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851891584
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDY R SMITH LVN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2018
-----------------------------------------------------
Last Update Date | 02/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 W WALNUT ST APT 30
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75949-8501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-238-6004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 84 W FRANK EDGE ST
-----------------------------------------------------
City | ALTO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75925-6005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-240-9370
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164X00000X
-----------------------------------------------------
Taxonomy Name | Licensed Vocational Nurse
-----------------------------------------------------
License Number | 214388
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------