Healthcare Provider Details

I. General information

NPI: 1093435448
Provider Name (Legal Business Name): SHEVON BORDE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3906 CHURCH RD
MOUNT LAUREL NJ
08054-1108
US

IV. Provider business mailing address

3906 CHURCH RD
MOUNT LAUREL NJ
08054-1108
US

V. Phone/Fax

Practice location:
  • Phone: 856-699-6077
  • Fax:
Mailing address:
  • Phone: 856-699-6077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP029315
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ15083000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: