Healthcare Provider Details

I. General information

NPI: 1194821793
Provider Name (Legal Business Name): MANDY RACHELLE SMOCK BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2327 NE SMOKEY HILL DR
LEES SUMMIT MO
64086-7019
US

IV. Provider business mailing address

2327 NE SMOKEY HILL DR
LEES SUMMIT MO
64086-7019
US

V. Phone/Fax

Practice location:
  • Phone: 816-246-2047
  • Fax: 816-246-2047
Mailing address:
  • Phone: 816-246-2047
  • Fax: 816-246-2047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number131015
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number14-86320-101
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: