Healthcare Provider Details

I. General information

NPI: 1477488047
Provider Name (Legal Business Name): MIAH RAVEN SYMONE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 TOWN CENTER RD
MATTESON IL
60443-2300
US

IV. Provider business mailing address

402 TOWN CENTER RD
MATTESON IL
60443-2300
US

V. Phone/Fax

Practice location:
  • Phone: 708-852-5179
  • Fax:
Mailing address:
  • Phone: 773-454-7157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209035832
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: