Provider Demographics
NPI:1366596066
Name:SMITH, REGINA CHRISTY (APN)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:CHRISTY
Last Name:SMITH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:CHRISTY
Other - Last Name:DODD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:6266 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-4713
Mailing Address - Country:US
Mailing Address - Phone:901-682-2595
Mailing Address - Fax:901-682-2549
Practice Address - Street 1:6266 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4713
Practice Address - Country:US
Practice Address - Phone:901-682-2595
Practice Address - Fax:901-682-2549
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11744363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1525669Medicaid
MS03989793Medicaid
TN10350I3285Medicare PIN