Healthcare Provider Details

I. General information

NPI: 1225004377
Provider Name (Legal Business Name): MARYELLEN T SMITH CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIR #1300 CENTRACARE CLINIC - WOMEN'S AND CHILDRENS
ST CLOUD MN
56303-5000
US

IV. Provider business mailing address

1900 CENTRACARE CIR #1300 CENTRACARE CLINIC - WOMEN'S AND CHILDRENS
ST CLOUD MN
56303-5000
US

V. Phone/Fax

Practice location:
  • Phone: 320-654-3610
  • Fax: 651-702-5305
Mailing address:
  • Phone: 320-654-3610
  • Fax: 952-883-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0735016
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR073501-6
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: