Healthcare Provider Details

I. General information

NPI: 1003698952
Provider Name (Legal Business Name): CAPRI SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5730 W ROOSEVELT RD
CHICAGO IL
60644-1580
US

IV. Provider business mailing address

5730 W ROOSEVELT RD
CHICAGO IL
60644-1580
US

V. Phone/Fax

Practice location:
  • Phone: 773-413-1700
  • Fax:
Mailing address:
  • Phone: 773-413-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209028445
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: