Basic Information
| Provider Information | |||||||||
| NPI: | 1336343698 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | ATC, PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 JOEL DR RM 1BE01 | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988727 | ||||||||
| FaxNumber: | 6156951483 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 JOEL DR RM 1BE01 | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988727 | ||||||||
| FaxNumber: | 6156951483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 08/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3622 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 085003827 | 05 | IL | MEDICAID | PENDING | 05 | TN | MEDICAID |