Healthcare Provider Details

I. General information

NPI: 1912348715
Provider Name (Legal Business Name): MANDALYN P SMITH CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 07/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 DOTHAN RD
ABBEVILLE AL
36310-2836
US

IV. Provider business mailing address

217 DOTHAN RD
ABBEVILLE AL
36310-2836
US

V. Phone/Fax

Practice location:
  • Phone: 334-585-6421
  • Fax:
Mailing address:
  • Phone: 334-585-6421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-121618
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: