Provider Demographics
NPI:1093361321
Name:SMITH-GROSS, VONGRETSHUN
Entity type:Individual
Prefix:
First Name:VONGRETSHUN
Middle Name:
Last Name:SMITH-GROSS
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 1:9846 HWY 31 E
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75705-2329
Mailing Address - Country:US
Mailing Address - Phone:903-525-3801
Mailing Address - Fax:903-525-3858
Practice Address - Street 1:9846 HWY 31 E
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75705-2329
Practice Address - Country:US
Practice Address - Phone:903-525-3801
Practice Address - Fax:903-525-3858
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN196090164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse