Provider Demographics
NPI:1083455307
Name:SMITH, CHANNEL (ST)
Entity type:Individual
Prefix:
First Name:CHANNEL
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3903 ROSEMONT DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-5625
Mailing Address - Country:US
Mailing Address - Phone:706-225-9854
Mailing Address - Fax:
Practice Address - Street 1:3903 ROSEMONT DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-5625
Practice Address - Country:US
Practice Address - Phone:706-225-9854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor