Provider Demographics
NPI:1427896265
Name:FLY-SMITH, JOANN
Entity type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:FLY-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 1:2106 MORTHLAND DR # 1149
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-5914
Mailing Address - Country:US
Mailing Address - Phone:469-667-7972
Mailing Address - Fax:
Practice Address - Street 1:2106 MORTHLAND DR # 1149
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-5914
Practice Address - Country:US
Practice Address - Phone:469-667-7972
Practice Address - Fax:888-379-3899
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300086594Medicaid