Healthcare Provider Details

I. General information

NPI: 1124303672
Provider Name (Legal Business Name): LYNN A SMITH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 08/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 PINE GROVE AVE
PORT HURON MI
48060-3511
US

IV. Provider business mailing address

PO BOX 713248
CINCINNATI OH
45271-0001
US

V. Phone/Fax

Practice location:
  • Phone: 810-987-5000
  • Fax: 952-442-3620
Mailing address:
  • Phone: 952-442-9770
  • Fax: 952-442-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704256168
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: