Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 175L00000X | Homeopath | 202879691 | WI |
Y | 225700000X | Massage Therapist | 1724-146 | WI |
NPI | 1154587061 |
---|---|
Provider Name | Anna Camille Smart |
First Address | Elroy, WI 53929-9635 |
Second Address | Elroy, WI 53929-9635 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/07/2008 |
Last Update Date | 12/10/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
202879691 | TAX ID (01) | WI |