Provider Demographics
NPI:1174663421
Name:SMITH, SUSAN M (DNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 E. KELSON AVE.
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446
Mailing Address - Country:US
Mailing Address - Phone:850-526-3434
Mailing Address - Fax:850-526-7743
Practice Address - Street 1:4215 E. KELSON AVE.
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446
Practice Address - Country:US
Practice Address - Phone:850-526-3434
Practice Address - Fax:850-526-7743
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3287482363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ24665Medicare UPIN
FLU3389AMedicare ID - Type Unspecified