Healthcare Provider Details

I. General information

NPI: 1679481022
Provider Name (Legal Business Name): OLIVIA MONIRA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W MAIN ST STE 211
BABYLON NY
11702-3009
US

IV. Provider business mailing address

400 W MAIN ST STE 211
BABYLON NY
11702-3009
US

V. Phone/Fax

Practice location:
  • Phone: 631-295-5450
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number036473
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: