Basic Information
| Provider Information | |||||||||
| NPI: | 1598326530 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JUSTINE | ||||||||
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| Credential: | CNIM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 N CENTRAL EXPY UNIT 2586 | ||||||||
| Address2: | |||||||||
| City: | MCKINNEY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750700139 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1653 LITITZ PIKE # 1054 | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176016507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037044621 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2019 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0600X | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic |
No ID Information.