Healthcare Provider Details

I. General information

NPI: 1578392684
Provider Name (Legal Business Name): SHARON ROSE SMITH LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 IRVING AVE
SYRACUSE NY
13210-2343
US

IV. Provider business mailing address

11 CHERRY ST APT A
PHOENIX NY
13135-2417
US

V. Phone/Fax

Practice location:
  • Phone: 315-426-7640
  • Fax:
Mailing address:
  • Phone: 912-430-0896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number345316
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: