1164104543 NPI number — CHANIQUA DOMINIQUE SMITH PMHNP-BC

Table of content: CHANIQUA DOMINIQUE SMITH PMHNP-BC (NPI 1164104543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164104543 NPI number — CHANIQUA DOMINIQUE SMITH PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
CHANIQUA
Provider Middle Name:
DOMINIQUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164104543
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
187 MARATHON WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHAVEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38671
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
187 MARATHON WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-727-8811
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/03/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  36433 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0808X , with the licence number: 906158 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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