Healthcare Provider Details

I. General information

NPI: 1083384218
Provider Name (Legal Business Name): CAITLYN MARIEL SMALLWOOD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAITLYN MARIEL PERKINS

II. Dates (important events)

Enumeration Date: 09/18/2021
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3738 LANDMARK DR STE A
LAFAYETTE IN
47905-6655
US

IV. Provider business mailing address

29943 NETWORK PL
CHICAGO IL
60673-1299
US

V. Phone/Fax

Practice location:
  • Phone: 765-807-2780
  • Fax:
Mailing address:
  • Phone: 317-706-3415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number28244460A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71013304A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: