1093044463 NPI number — PAMELA MICHELE SMITH CRNA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093044463 NPI number — PAMELA MICHELE SMITH CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
PAMELA
Provider Middle Name:
MICHELE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEWIS
Provider Other First Name:
PAMELA
Provider Other Middle Name:
MICHELE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093044463
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 37090
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21297-3090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-295-9360
Provider Business Mailing Address Fax Number:
703-295-9369

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5818 HARBOUR VIEW BLVD
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
SUFFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23435-3315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-483-6100
Provider Business Practice Location Address Fax Number:
703-295-9369
Provider Enumeration Date:
12/15/2009

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: 163W00000X , with the licence number:  237361 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 0024169997 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8053790 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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