Healthcare Provider Details

I. General information

NPI: 1104971373
Provider Name (Legal Business Name): JOHNNY LEE SMITH APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 WEST COURT
JASPER AR
72641
US

IV. Provider business mailing address

PO BOX 445
JASPER AR
72641-0445
US

V. Phone/Fax

Practice location:
  • Phone: 870-446-2203
  • Fax: 870-446-2206
Mailing address:
  • Phone: 870-446-2203
  • Fax: 870-446-2206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA01227
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: