MEDICARE: SMITHA SYAMALA KOMATREDDY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	1102099	TX

General Provider Information

NPI Number	:	1174413470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SMITHA SYAMALA KOMATREDDY

Provider Business Mailing Address
First Line	:	121 CROSS TIMBERS TRL
Second Line	:
City	:	COPPELL
State	:	TX
Zip	:	75019-6714
Country	:	US
Telephone Number	:	203-273-6206
Fax Number	:

Provider Business Practice Location Address
First Line	:	823 IRA E WOODS AVE STE 200
Second Line	:
City	:	GRAPEVINE
State	:	TX
Zip	:	76051-4096
Country	:	US
Telephone Number	:	817-722-6078
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2025
Last Update Date	:	07/08/2025

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Directions to “ SMITHA SYAMALA KOMATREDDY ” Practice Location

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