Provider Demographics
NPI:1528651460
Name:SMOLL, JUDITH A
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:SMOLL
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 1:2936 DUSK CAMP RUN RD
Mailing Address - Street 2:
Mailing Address - City:SAND FORK
Mailing Address - State:WV
Mailing Address - Zip Code:26430-8105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2936 DUSK CAMP RUN RD
Practice Address - Street 2:
Practice Address - City:SAND FORK
Practice Address - State:WV
Practice Address - Zip Code:26430-8105
Practice Address - Country:US
Practice Address - Phone:304-462-4174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker