Provider Demographics
NPI:1063803682
Name:SMITH, DEIDRA GAYLE (RN)
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:GAYLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9527 W RIDGE TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:SODDY DAISY
Mailing Address - State:TN
Mailing Address - Zip Code:37379-4018
Mailing Address - Country:US
Mailing Address - Phone:423-842-3013
Mailing Address - Fax:423-842-5050
Practice Address - Street 1:9527 W RIDGE TRAIL RD
Practice Address - Street 2:
Practice Address - City:SODDY DAISY
Practice Address - State:TN
Practice Address - Zip Code:37379-4018
Practice Address - Country:US
Practice Address - Phone:423-842-3013
Practice Address - Fax:423-842-5050
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000188381163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse