Healthcare Provider Details

I. General information

NPI: 1467005009
Provider Name (Legal Business Name): STEPHANIE I SMITH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE I O'BRIAN

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 MEMORIAL DR STE 210
ALTON IL
62002-6751
US

IV. Provider business mailing address

4 MEMORIAL DR STE 210
ALTON IL
62002-6704
US

V. Phone/Fax

Practice location:
  • Phone: 618-463-5905
  • Fax: 618-463-5935
Mailing address:
  • Phone: 618-463-5905
  • Fax: 618-463-5935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number277005238
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209019631
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: