Healthcare Provider Details

I. General information

NPI: 1508470527
Provider Name (Legal Business Name): LYLA MARIE SMITH APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 GEORGIA ST
STARKE FL
32091-1816
US

IV. Provider business mailing address

23343 NW COUNTY ROAD 236
HIGH SPRINGS FL
32643-9669
US

V. Phone/Fax

Practice location:
  • Phone: 904-364-2900
  • Fax: 904-364-2901
Mailing address:
  • Phone: 386-454-0698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2149562
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11018606
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: