1063693109 NPI number — ALEXIS LAVERNE SMITH FNP-C

Table of content: ALEXIS LAVERNE SMITH FNP-C (NPI 1063693109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063693109 NPI number — ALEXIS LAVERNE SMITH FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
ALEXIS
Provider Middle Name:
LAVERNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
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:
1063693109
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/02/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 744786
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-4786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-834-2450
Provider Business Mailing Address Fax Number:
704-671-5331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1223 SPRUCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELMONT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28012-3371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
980-834-8800
Provider Business Practice Location Address Fax Number:
980-834-9879
Provider Enumeration Date:
11/16/2007

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: 363LF0000X , with the licence number:  5003751 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1063693109 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: NP2732 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com