Healthcare Provider Details

I. General information

NPI: 1609226422
Provider Name (Legal Business Name): CHESTER CORY SMITH PHD, NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 DULLES DR
LAFAYETTE LA
70506-3718
US

IV. Provider business mailing address

1340 BROAD AVE STE 300A
GULFPORT MS
39501-2404
US

V. Phone/Fax

Practice location:
  • Phone: 337-408-0815
  • Fax: 337-991-9288
Mailing address:
  • Phone: 228-575-2700
  • Fax: 228-575-2710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number901546
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: