Healthcare Provider Details

I. General information

NPI: 1164771614
Provider Name (Legal Business Name): VINCENT ROSS SMITH DNP, ANP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2012
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 E 89TH AVE
MERRILLVILLE IN
46410-8162
US

IV. Provider business mailing address

820 SPRINGER DR
LOMBARD IL
60148-6413
US

V. Phone/Fax

Practice location:
  • Phone: 219-769-7062
  • Fax: 630-495-1770
Mailing address:
  • Phone: 708-634-4602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number28250476A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9310400
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN80537
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP 22695
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN001802
License Number StateNV
# 6
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN 805484
License Number StateCA
# 7
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71008935A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: