Provider Demographics
NPI:1902936297
Name:SMITH, LOIS
Entity Type:Individual
Prefix:MS
First Name:LOIS
Middle Name:
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 1:5832 MONTERREY DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-3980
Mailing Address - Country:US
Mailing Address - Phone:817-429-5785
Mailing Address - Fax:817-429-5785
Practice Address - Street 1:5832 MONTERREY DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-3980
Practice Address - Country:US
Practice Address - Phone:817-429-5785
Practice Address - Fax:817-429-5785
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2021-12-01
Deactivation Date:2021-01-26
Deactivation Code:
Reactivation Date:2021-12-01
Provider Licenses
StateLicense IDTaxonomies
TX1167943747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000688000OtherTDADS