Healthcare Provider Details

I. General information

NPI: 1790148385
Provider Name (Legal Business Name): CANDACE YVETTE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE SLU DIVISION OF EMERGENCY MEDICINE
SAINT LOUIS MO
63110-2539
US

IV. Provider business mailing address

3635 VISTA AVE SLU DIVISION OF EMERGENCY MEDICINE
SAINT LOUIS MO
63110-2539
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-7133
  • Fax:
Mailing address:
  • Phone: 314-268-7133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number82603
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: