Provider Demographics
NPI:1538238969
Name:SMITH, HEATHER DEETTE (LPN)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:DEETTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 N SHOOP AVE
Mailing Address - Street 2:LOT 114
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-1847
Mailing Address - Country:US
Mailing Address - Phone:419-704-8585
Mailing Address - Fax:
Practice Address - Street 1:325 BEECH ST
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1448
Practice Address - Country:US
Practice Address - Phone:419-335-2313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376K00000X
OH129339164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPN 129339OtherSTATE OF OHIO LPN LICENSURE