MEDICARE: WAKESHA SMITH

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	172A00000X	Driver	21364677	NC

General Provider Information

NPI Number	:	1417679390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WAKESHA SMITH

Provider Business Mailing Address
First Line	:	1445 SAMUEL ST APT 232
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28206-1568
Country	:	US
Telephone Number	:	323-496-6813
Fax Number	:

Provider Business Practice Location Address
First Line	:	1445 SAMUEL ST APT 232
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28206-1568
Country	:	US
Telephone Number	:	323-496-6813
Fax Number	:

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

Provider Enumeration Date	:	09/16/2022
Last Update Date	:	09/16/2022

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Directions to “ WAKESHA SMITH ” Practice Location

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