Provider Demographics
NPI:1083814479
Name:SMITH, HEATHER NICOLE (PT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 GOSHEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CHURCH HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37642-5038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-224-5510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000006264225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist