Healthcare Provider Details

I. General information

NPI: 1790243723
Provider Name (Legal Business Name): JENNIFER SMITH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2019
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 SARNO RD
MELBOURNE FL
32935-3084
US

IV. Provider business mailing address

PO BOX 1137
MELBOURNE FL
32902-1137
US

V. Phone/Fax

Practice location:
  • Phone: 321-241-6800
  • Fax: 321-241-6890
Mailing address:
  • Phone: 321-952-9696
  • Fax: 321-952-7937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN235782
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN11018703
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: