Provider Demographics
NPI:1194419549
Name:SMILEY, LATRESE AMILIA
Entity type:Individual
Prefix:
First Name:LATRESE
Middle Name:AMILIA
Last Name:SMILEY
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 1:11 LINCOLN CT
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-3912
Mailing Address - Country:US
Mailing Address - Phone:631-219-3931
Mailing Address - Fax:
Practice Address - Street 1:11 LINCOLN CT
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-3912
Practice Address - Country:US
Practice Address - Phone:631-219-3931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345469164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse