Healthcare Provider Details

I. General information

NPI: 1497266738
Provider Name (Legal Business Name): CONSTANCIA SMITH NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2017
Last Update Date: 10/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118-11 GUY BREWER BOULEVARD
JAMAICA NY
11434
US

IV. Provider business mailing address

859 SPRAGUE STREET
NORTH BALDWIN NY
11510-1429
US

V. Phone/Fax

Practice location:
  • Phone: 718-945-7150
  • Fax: 718-945-2596
Mailing address:
  • Phone: 646-732-5608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF341225-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: