Healthcare Provider Details

I. General information

NPI: 1427709542
Provider Name (Legal Business Name): MARY GRACE SMILEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

IV. Provider business mailing address

PO BOX 1680
HUNTINGTON WV
25717-1680
US

V. Phone/Fax

Practice location:
  • Phone: 855-446-5937
  • Fax:
Mailing address:
  • Phone: 304-781-5159
  • Fax: 304-523-8115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.009034RX
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2756
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: