Healthcare Provider Details

I. General information

NPI: 1922647510
Provider Name (Legal Business Name): NICOLE SMYTHE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2019
Last Update Date: 12/30/2019
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 HOLLAND PARK AVE
FAYETTEVILLE NC
28314-6361
US

IV. Provider business mailing address

5320 HOLLAND PARK AVE
FAYETTEVILLE NC
28314-6361
US

V. Phone/Fax

Practice location:
  • Phone: 910-315-0609
  • Fax: 910-920-9074
Mailing address:
  • Phone: 910-315-0609
  • Fax: 910-920-9074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number215535
License Number State
# 2
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number215535
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: