Provider Demographics
NPI:1144303371
Name:SMITH, TRISHA JEAN L (MPH, LPN)
Entity type:Individual
Prefix:
First Name:TRISHA JEAN
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:MPH, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 BAYSHORE DR
Mailing Address - Street 2:
Mailing Address - City:SNEADS FERRY
Mailing Address - State:NC
Mailing Address - Zip Code:28460-9509
Mailing Address - Country:US
Mailing Address - Phone:760-805-8573
Mailing Address - Fax:
Practice Address - Street 1:152 BAYSHORE DR
Practice Address - Street 2:
Practice Address - City:SNEADS FERRY
Practice Address - State:NC
Practice Address - Zip Code:28460-9509
Practice Address - Country:US
Practice Address - Phone:760-805-8573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN221053164X00000X
174N00000X
NC30682164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEPS015630Medicare ID - Type UnspecifiedMEDI-CAL INP