Provider Demographics
NPI:1154593176
Name:SMITH, THERESA G
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:G
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 1:880 KEMPSVILLE RD
Mailing Address - Street 2:STE 2200
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3990
Mailing Address - Country:US
Mailing Address - Phone:757-539-3911
Mailing Address - Fax:757-925-0615
Practice Address - Street 1:2790 GODWIN BLVD
Practice Address - Street 2:SUITE 360
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8151
Practice Address - Country:US
Practice Address - Phone:757-539-3911
Practice Address - Fax:757-925-0615
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167593176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife