Provider Demographics
NPI:1871058982
Name:SMITH, SHARON DIANNE
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:DIANNE
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 1:1810 MERIADOC RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-3349
Mailing Address - Country:US
Mailing Address - Phone:229-474-1904
Mailing Address - Fax:
Practice Address - Street 1:129 HOLTON RD
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:FL
Practice Address - Zip Code:32343-6511
Practice Address - Country:US
Practice Address - Phone:229-474-1904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-02
Last Update Date:2019-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20181534P163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL19000019265Medicaid