Healthcare Provider Details

I. General information

NPI: 1609086230
Provider Name (Legal Business Name): MARY COLLEEN SMITH F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 N POLK AVE ROOM 4
FRESNO CA
93722-5334
US

IV. Provider business mailing address

635 E NORMAL AVE
FRESNO CA
93704-6110
US

V. Phone/Fax

Practice location:
  • Phone: 559-274-4700
  • Fax:
Mailing address:
  • Phone: 559-497-1610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number3524111
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number3524111
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3524111
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: