Provider Demographics
NPI:1285608703
Name:SMITH, TARA SHANNON (CNM)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:SHANNON
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26005 RIDGE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DAMASCUS
Mailing Address - State:MD
Mailing Address - Zip Code:20872-1892
Mailing Address - Country:US
Mailing Address - Phone:301-414-2300
Mailing Address - Fax:301-414-2306
Practice Address - Street 1:26005 RIDGE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DAMASCUS
Practice Address - State:MD
Practice Address - Zip Code:20872-1892
Practice Address - Country:US
Practice Address - Phone:301-414-2300
Practice Address - Fax:301-414-2306
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024165986176B00000X
VA0001146963163W00000X
MDAC00911367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No163W00000XNursing Service ProvidersRegistered Nurse
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010130484Medicaid
NC7002042Medicaid
VA175079OtherANTHEM
VA010061873Medicaid
VA2125746OtherUHC/MAMSI
VA75928NOtherSENTARA/OPTIMA
VA010061873Medicaid