Healthcare Provider Details

I. General information

NPI: 1154536928
Provider Name (Legal Business Name): EMILY DIANNE SMITH PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PLZ
DAYTON OH
45404-1898
US

IV. Provider business mailing address

3891 STRALEY RD
XENIA OH
45385-9619
US

V. Phone/Fax

Practice location:
  • Phone: 937-641-3000
  • Fax:
Mailing address:
  • Phone: 937-766-7195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberCOA07920-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: