Provider Demographics
NPI:1588162341
Name:SMITH, GENQUETTA MICHELLE (INDEPENDE CONTRACTOR)
Entity type:Individual
Prefix:
First Name:GENQUETTA
Middle Name:MICHELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:INDEPENDE CONTRACTOR
Other - Prefix:MS
Other - First Name:QUEEN
Other - Middle Name:
Other - Last Name:QUETTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 418
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33583-0418
Mailing Address - Country:US
Mailing Address - Phone:727-657-8044
Mailing Address - Fax:
Practice Address - Street 1:7938 CARRIAGE POINTE DR
Practice Address - Street 2:
Practice Address - City:GIBSONTON
Practice Address - State:FL
Practice Address - Zip Code:33534-3007
Practice Address - Country:US
Practice Address - Phone:727-657-8044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2470A2800X, 2472R0900X, 374U00000X
FL131219372600000X, 3747P1801X
FL1311219376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No2470A2800XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health InformationAssistant Record Technician
No2472R0900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherRenal Dialysis
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL131219OtherCERTIFIED NURSING ASSISTANT