Healthcare Provider Details

I. General information

NPI: 1821264565
Provider Name (Legal Business Name): ANGELA ELAINE SMITH PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2008
Last Update Date: 04/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8331 N DAVIS HWY
PENSACOLA FL
32514-6094
US

IV. Provider business mailing address

10140 CENTURION PKWY N
JACKSONVILLE FL
32256-0532
US

V. Phone/Fax

Practice location:
  • Phone: 850-505-4700
  • Fax: 850-505-4711
Mailing address:
  • Phone: 904-697-4100
  • Fax: 904-697-5102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN9473715
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number130810
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberAPRN9473715
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: