Provider Demographics
NPI:1043023708
Name:SMITH, DIVONICA S
Entity type:Individual
Prefix:
First Name:DIVONICA
Middle Name:S
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 1:1402 JONES ST STE 240
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68102-3218
Mailing Address - Country:US
Mailing Address - Phone:402-915-5171
Mailing Address - Fax:402-256-6651
Practice Address - Street 1:1402 JONES ST STE 240
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-3218
Practice Address - Country:US
Practice Address - Phone:402-915-5174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide