Provider Demographics
NPI:1326189614
Name:SMITH, THYLLIS GARDENIA
Entity type:Individual
Prefix:
First Name:THYLLIS
Middle Name:GARDENIA
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:PO BOX 1165
Mailing Address - Street 2:
Mailing Address - City:RAMSEUR
Mailing Address - State:NC
Mailing Address - Zip Code:27316
Mailing Address - Country:US
Mailing Address - Phone:336-402-5592
Mailing Address - Fax:336-643-0693
Practice Address - Street 1:339 RAMSEUR JULIAN RD
Practice Address - Street 2:
Practice Address - City:RAMSEUR
Practice Address - State:NC
Practice Address - Zip Code:27316
Practice Address - Country:US
Practice Address - Phone:336-402-5592
Practice Address - Fax:336-643-0693
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408719Medicaid
NC8301180Medicaid