Provider Demographics
NPI:1861167363
Name:SMITH, TYANGALA BRACEY
Entity type:Individual
Prefix:
First Name:TYANGALA
Middle Name:BRACEY
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 1:12104 HARMONY CIR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-9534
Mailing Address - Country:US
Mailing Address - Phone:601-454-9778
Mailing Address - Fax:
Practice Address - Street 1:12104 HARMONY CIR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-9534
Practice Address - Country:US
Practice Address - Phone:601-454-9778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904739363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily