Healthcare Provider Details

I. General information

NPI: 1700867116
Provider Name (Legal Business Name): DONNA JEAN SMITH LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SNYDER DR
CORTLAND NY
13045-1005
US

IV. Provider business mailing address

4 SNYDER DR
CORTLAND NY
13045-1005
US

V. Phone/Fax

Practice location:
  • Phone: 607-428-0518
  • Fax: 607-428-0518
Mailing address:
  • Phone: 607-428-0518
  • Fax: 607-428-0518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number275146-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: