Healthcare Provider Details

I. General information

NPI: 1720434046
Provider Name (Legal Business Name): ANDREA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2016
Last Update Date: 10/04/2025
Certification Date: 10/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 W REDSKIN TRL
WAPAKONETA OH
45895-9349
US

IV. Provider business mailing address

1001 BELLEFONTAINE AVE
LIMA OH
45804-2800
US

V. Phone/Fax

Practice location:
  • Phone: 419-738-5151
  • Fax: 419-941-1092
Mailing address:
  • Phone: 419-998-4575
  • Fax: 419-998-4586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.019808
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: