Provider Demographics
NPI:1548883143
Name:SMITH, AMIIAH J
Entity type:Individual
Prefix:
First Name:AMIIAH
Middle Name:J
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 1:2626 PARKLAND DR
Mailing Address - Street 2:
Mailing Address - City:DISTRICT HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20747-4802
Mailing Address - Country:US
Mailing Address - Phone:240-416-6313
Mailing Address - Fax:
Practice Address - Street 1:3700 9TH ST SE APT 823
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-4016
Practice Address - Country:US
Practice Address - Phone:202-390-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS5300664541993747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCR60238903Medicaid