Healthcare Provider Details

I. General information

NPI: 1467858712
Provider Name (Legal Business Name): GRETA SMITH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 E MAIN ST
GALATIA IL
62935-1300
US

IV. Provider business mailing address

124 E MAIN ST
GALATIA IL
62935-1300
US

V. Phone/Fax

Practice location:
  • Phone: 618-268-4083
  • Fax: 618-268-4104
Mailing address:
  • Phone: 618-268-4083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209012164
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: