Provider Demographics
NPI:1174881767
Name:SMYLIE, HEATH HERNDON
Entity type:Individual
Prefix:
First Name:HEATH
Middle Name:HERNDON
Last Name:SMYLIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6250 OLD CANTON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-2946
Mailing Address - Country:US
Mailing Address - Phone:601-968-1000
Mailing Address - Fax:601-944-9780
Practice Address - Street 1:6250 OLD CANTON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2946
Practice Address - Country:US
Practice Address - Phone:601-968-1000
Practice Address - Fax:601-944-9780
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant