Healthcare Provider Details

I. General information

NPI: 1750113783
Provider Name (Legal Business Name): TYLER JUSTIN SMITH DNP, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 SE HILLMOOR DR STE C-207
PORT SAINT LUCIE FL
34952-7574
US

IV. Provider business mailing address

1801 SE HILLMOOR DR STE C-207
PORT SAINT LUCIE FL
34952-7574
US

V. Phone/Fax

Practice location:
  • Phone: 772-335-4234
  • Fax: 772-335-4236
Mailing address:
  • Phone: 772-335-4234
  • Fax: 772-335-4236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11035424
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: