Provider Demographics
NPI:1174136782
Name:SMITH, TAYLOR REENAE
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:REENAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 53
Mailing Address - Street 2:
Mailing Address - City:DANESE
Mailing Address - State:WV
Mailing Address - Zip Code:25831-0053
Mailing Address - Country:US
Mailing Address - Phone:304-890-2901
Mailing Address - Fax:
Practice Address - Street 1:6 YELLOW WOOD WAY APT 314
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-7132
Practice Address - Country:US
Practice Address - Phone:304-890-2901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant