Provider Demographics
NPI:1538791629
Name:SMITH, TIWANNA CATHLEEN
Entity type:Individual
Prefix:
First Name:TIWANNA
Middle Name:CATHLEEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIWANNA
Other - Middle Name:CATHLEEN
Other - Last Name:BARNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:160 MANLEY ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-2110
Mailing Address - Country:US
Mailing Address - Phone:616-477-6999
Mailing Address - Fax:
Practice Address - Street 1:160 MANLEY ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2110
Practice Address - Country:US
Practice Address - Phone:616-477-6999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703097293164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse