Healthcare Provider Details

I. General information

NPI: 1467196295
Provider Name (Legal Business Name): MICHAEL WILLIAM SMITH APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S MAIN ST STE 2
WILDWOOD FL
34785-4542
US

IV. Provider business mailing address

226 MAGELLAN CIR
MINNEOLA FL
34715-5702
US

V. Phone/Fax

Practice location:
  • Phone: 352-643-6699
  • Fax: 888-675-8377
Mailing address:
  • Phone: 954-465-3008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11019097
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: