Healthcare Provider Details

I. General information

NPI: 1811620370
Provider Name (Legal Business Name): JENNIFER LYNN SMITH FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2022
Last Update Date: 07/02/2022
Certification Date: 07/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 LEROUX ST
DONIPHAN MO
63935-1038
US

IV. Provider business mailing address

1988 RIPLEY ROUTE CC
DONIPHAN MO
63935-7887
US

V. Phone/Fax

Practice location:
  • Phone: 573-996-2136
  • Fax:
Mailing address:
  • Phone: 573-382-6524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2022025648
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: