Provider Demographics
NPI:1235875311
Name:SMITH, ERIN THERESA
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:THERESA
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:THERESA
Other - Last Name:MOGAVERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10752 DEERWOOD PARK BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-4846
Mailing Address - Country:US
Mailing Address - Phone:904-800-4775
Mailing Address - Fax:
Practice Address - Street 1:10752 DEERWOOD PARK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-4846
Practice Address - Country:US
Practice Address - Phone:904-800-4775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2024-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11033223363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health