Provider Demographics
NPI:1447024815
Name:SMITH, TYSHAY MONNA (CRANIAL PROSTHETIC)
Entity type:Individual
Prefix:
First Name:TYSHAY
Middle Name:MONNA
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRANIAL PROSTHETIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 N HUALAPAI WAY UNIT 1058
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-8057
Mailing Address - Country:US
Mailing Address - Phone:213-909-1151
Mailing Address - Fax:
Practice Address - Street 1:3450 N HUALAPAI WAY UNIT 1058
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-8057
Practice Address - Country:US
Practice Address - Phone:213-909-1151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
335E00000X, 374U00000X
NV335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No374U00000XNursing Service Related ProvidersHome Health Aide