1124084033 NPI number — PAULA KIM SMITH CWHNP

Table of content: PAULA KIM SMITH CWHNP (NPI 1124084033)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124084033 NPI number — PAULA KIM SMITH CWHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
PAULA
Provider Middle Name:
KIM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CWHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DIEHL
Provider Other First Name:
PAULA
Provider Other Middle Name:
KIM
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124084033
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 16568
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32245-6568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-472-2300
Provider Business Mailing Address Fax Number:
904-472-2330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 SHIRCLIFF WAY
Provider Second Line Business Practice Location Address:
STE 200 DILLON BLDG
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32204-4757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-384-3699
Provider Business Practice Location Address Fax Number:
904-384-8529
Provider Enumeration Date:
04/21/2006

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: 363LW0102X , with the licence number:  RN120829 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LX0001X , with the licence number: ARNP 9348308 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 007251200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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