Provider Demographics
NPI:1164837357
Name:SMALLWOOD, PAULA TIFFANY NICOLE
Entity type:Individual
Prefix:MISS
First Name:PAULA
Middle Name:TIFFANY NICOLE
Last Name:SMALLWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAULA
Other - Middle Name:TIFFANY NICOLE
Other - Last Name:STINNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:109 HILLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-1807
Mailing Address - Country:US
Mailing Address - Phone:270-899-0175
Mailing Address - Fax:844-688-4227
Practice Address - Street 1:109 HILLVIEW DR
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-1807
Practice Address - Country:US
Practice Address - Phone:270-899-0175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY201154945222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist