Healthcare Provider Details

I. General information

NPI: 1376554303
Provider Name (Legal Business Name): JACQUELINE RUARK SMITH CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 11/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 DENTON PLZ
DENTON MD
21629-9501
US

IV. Provider business mailing address

1400 FRONT AVE STE 300
LUTHERVILLE MD
21093-5364
US

V. Phone/Fax

Practice location:
  • Phone: 443-606-2300
  • Fax: 443-606-2305
Mailing address:
  • Phone: 410-296-7190
  • Fax: 443-991-7768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR073073
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: