1275597320 NPI number — HARRIETT WILLIEMAE SMITH-MCKINNEY PA-C

Table of content: HARRIETT WILLIEMAE SMITH-MCKINNEY PA-C (NPI 1275597320)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275597320 NPI number — HARRIETT WILLIEMAE SMITH-MCKINNEY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH-MCKINNEY
Provider First Name:
HARRIETT
Provider Middle Name:
WILLIEMAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BYNOM
Provider Other First Name:
HARRIETT
Provider Other Middle Name:
SMITH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275597320
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 CITRUS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34748-3063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-347-5225
Provider Business Mailing Address Fax Number:
352-347-1073

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10762 SE US HIGHWAY 441
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVIEW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34420-3805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-347-5225
Provider Business Practice Location Address Fax Number:
352-347-1073
Provider Enumeration Date:
04/14/2006

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: 363AM0700X , with the licence number:  PA 2621 , 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: 008159200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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