Healthcare Provider Details

I. General information

NPI: 1760996375
Provider Name (Legal Business Name): CAROLYN SUE SMITH MSN-RN-CNS-CWOCN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 N WABASH AVE
MARION IN
46952-2612
US

IV. Provider business mailing address

441 N WABASH AVE
MARION IN
46952-2612
US

V. Phone/Fax

Practice location:
  • Phone: 765-660-6670
  • Fax: 765-671-3392
Mailing address:
  • Phone: 765-660-6670
  • Fax: 765-671-3392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0900X
TaxonomyEnterostomal Therapy Registered Nurse
License Number28103859A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number28103859A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code364SC1501X
TaxonomyCommunity Health/Public Health Clinical Nurse Specialist
License Number28103859A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28103859A
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code163WC2100X
TaxonomyContinence Care Registered Nurse
License Number28103859A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: