Provider Demographics
NPI:1861253072
Name:SMITH, CARLY JEANANN
Entity type:Individual
Prefix:MS
First Name:CARLY
Middle Name:JEANANN
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 1:4631 WHITE OAK RD NE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43106-9768
Mailing Address - Country:US
Mailing Address - Phone:740-505-2751
Mailing Address - Fax:
Practice Address - Street 1:4631 WHITE OAK RD NE
Practice Address - Street 2:
Practice Address - City:BLOOMINGBURG
Practice Address - State:OH
Practice Address - Zip Code:43106-9768
Practice Address - Country:US
Practice Address - Phone:740-505-2751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide