Provider Demographics
NPI:1982918264
Name:SMITH, WANDA FAYE (RN)
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:FAYE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:FAYE
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:126 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NEWBERN
Mailing Address - State:TN
Mailing Address - Zip Code:38059
Mailing Address - Country:US
Mailing Address - Phone:731-627-2221
Mailing Address - Fax:731-627-6152
Practice Address - Street 1:126 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:NEWBERN
Practice Address - State:TN
Practice Address - Zip Code:38059
Practice Address - Country:US
Practice Address - Phone:731-627-2221
Practice Address - Fax:731-627-2221
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN115705163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse