Provider Demographics
NPI:1669067575
Name:SMITH, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
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 1:97 SILVERAGE AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38109-1823
Mailing Address - Country:US
Mailing Address - Phone:901-378-4004
Mailing Address - Fax:
Practice Address - Street 1:97 SILVERAGE AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38109-1823
Practice Address - Country:US
Practice Address - Phone:901-435-6138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2025-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN311ZA0620X, 3747A0650X, 310400000X, 172A00000X, 347C00000X, 3747P1801X
253Z00000X
TN4352376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No253Z00000XAgenciesIn Home Supportive Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No172A00000XOther Service ProvidersDriver
No347C00000XTransportation ServicesPrivate Vehicle
No376G00000XNursing Service Related ProvidersNursing Home Administrator
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ006138Medicaid