Provider Demographics
NPI:1518367358
Name:SMITH, FAITH NICOLE (PTA, LAT, ATC)
Entity type:Individual
Prefix:
First Name:FAITH
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-264-6000
Mailing Address - Fax:
Practice Address - Street 1:904 MUNICIPAL DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2973
Practice Address - Country:US
Practice Address - Phone:601-724-7310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-29
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA-7032225200000X
MSAT05002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant