Healthcare Provider Details

I. General information

NPI: 1760152755
Provider Name (Legal Business Name): ANGELIQUE SMITH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8135 CALUMET AVE
MUNSTER IN
46321-1701
US

IV. Provider business mailing address

8135 CALUMET AVE
MUNSTER IN
46321-1701
US

V. Phone/Fax

Practice location:
  • Phone: 219-513-2000
  • Fax:
Mailing address:
  • Phone: 219-513-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209025279
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71011903B
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28210533A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: