Healthcare Provider Details

I. General information

NPI: 1770928343
Provider Name (Legal Business Name): SHAFONNE MONIQUE SMITH WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 HOLLY HILLS AVE
SAINT LOUIS MO
63111-2410
US

IV. Provider business mailing address

401 HOLLY HILLS AVE
SAINT LOUIS MO
63111-2410
US

V. Phone/Fax

Practice location:
  • Phone: 314-353-5190
  • Fax: 314-353-7631
Mailing address:
  • Phone: 314-353-5190
  • Fax: 314-353-7631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2016009888
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2024011653
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2016009888
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number28208566A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: