Healthcare Provider Details

I. General information

NPI: 1023314143
Provider Name (Legal Business Name): JOHNELLE R SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2011
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 BEACON ST STE 3C
BROOKLINE MA
02446-3806
US

IV. Provider business mailing address

1180 BEACON ST STE 3C
BROOKLINE MA
02446-3806
US

V. Phone/Fax

Practice location:
  • Phone: 617-202-9222
  • Fax: 617-879-0933
Mailing address:
  • Phone: 617-202-9222
  • Fax: 617-879-0933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4301078591
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: