Basic Information
| Provider Information | |||||||||
| NPI: | 1689062457 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | |||||||||
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| Credential: | HAS | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | JEANNIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | HAS | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8800 SE SUNNYSIDE RD STE 300N | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970155703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812862999 | ||||||||
| FaxNumber: | 5126074893 | ||||||||
| Practice Location | |||||||||
| Address1: | 8911 PATTERSON AVE STE B | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232296370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042820055 | ||||||||
| FaxNumber: | 8042824762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2015 | ||||||||
| LastUpdateDate: | 01/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | VA | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237700000X | 2102002752 | VA | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.