Healthcare Provider Details

I. General information

NPI: 1720860620
Provider Name (Legal Business Name): ABIGAIL SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 WALNUT ST
RACINE OH
45771-5004
US

IV. Provider business mailing address

808 WALNUT ST
RACINE OH
45771-5004
US

V. Phone/Fax

Practice location:
  • Phone: 740-418-3833
  • Fax:
Mailing address:
  • Phone: 740-418-3833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN.CNP.0035168
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: