Healthcare Provider Details

I. General information

NPI: 1962885202
Provider Name (Legal Business Name): SHELBY SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MICHIGAN AVE NW
WASHINGTON DC
20010-2916
US

IV. Provider business mailing address

1417 HIGHLAND DR
SILVER SPRING MD
20910-1525
US

V. Phone/Fax

Practice location:
  • Phone: 301-367-4439
  • Fax:
Mailing address:
  • Phone: 301-367-4439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number687196
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number382605
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN1044497
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: