Provider Demographics
NPI:1215621404
Name:SMYTH, STACIA
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:
Last Name:SMYTH
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 1:2139 MARTIN AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-3350
Mailing Address - Country:US
Mailing Address - Phone:937-250-4771
Mailing Address - Fax:
Practice Address - Street 1:1375 HEMLOCK DR
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-3540
Practice Address - Country:US
Practice Address - Phone:937-516-6499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant