Healthcare Provider Details

I. General information

NPI: 1609816446
Provider Name (Legal Business Name): SUE M SMITH M.S.R.N.C.,CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 04/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8402 BLACKJACK ROAD EXT
MOUNT VERNON OH
43050-9193
US

IV. Provider business mailing address

PO BOX 4670
NEWARK OH
43058-4670
US

V. Phone/Fax

Practice location:
  • Phone: 740-397-0442
  • Fax: 740-788-3424
Mailing address:
  • Phone: 740-522-8477
  • Fax: 740-788-3424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN-191200
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: