Provider Demographics
NPI:1144926676
Name:SMITH, DEANDRA LATISHA (PMHNP)
Entity type:Individual
Prefix:
First Name:DEANDRA
Middle Name:LATISHA
Last Name:SMITH
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 RAMSEY WAY
Mailing Address - Street 2:
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-2198
Mailing Address - Country:US
Mailing Address - Phone:901-643-0993
Mailing Address - Fax:
Practice Address - Street 1:6000 RAMSEY WAY
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2198
Practice Address - Country:US
Practice Address - Phone:901-643-0993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN32918363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty