Provider Demographics
NPI:1538702691
Name:SMITH, DESIRAY
Entity type:Individual
Prefix:
First Name:DESIRAY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12405 DUCK RIVER RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3815
Mailing Address - Country:US
Mailing Address - Phone:804-986-5002
Mailing Address - Fax:
Practice Address - Street 1:12405 DUCK RIVER RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3815
Practice Address - Country:US
Practice Address - Phone:804-986-5002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider