1639373483 NPI number — MRS. SUSAN J SMITH RNC FNP

Table of content: MRS. SUSAN J SMITH RNC FNP (NPI 1639373483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639373483 NPI number — MRS. SUSAN J SMITH RNC FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
SUSAN
Provider Middle Name:
J
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RNC FNP
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:
1639373483
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 N WESTWOOD BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POPLAR BLUFF
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63901-3318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-339-0909
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 N WESTWOOD BLVD
Provider Second Line Business Practice Location Address:
BOX 658
Provider Business Practice Location Address City Name:
POPLAR BLUFF
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63901-3318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-339-0909
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2007

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: 363LP2300X , with the licence number:  108177 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 425270931 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 425270907 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 425270956 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 425270923 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 425270949 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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