Healthcare Provider Details

I. General information

NPI: 1326781774
Provider Name (Legal Business Name): JOHN ALBERT SMITH AGCNS-BC, CMSRN-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 04/14/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4481 SUGAR MAPLE DR
WPAFB OH
45433-5536
US

IV. Provider business mailing address

2706 OAK TRCE
BEAVERCREEK OH
45431-8572
US

V. Phone/Fax

Practice location:
  • Phone: 937-713-7526
  • Fax:
Mailing address:
  • Phone: 850-376-7011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberAPRN11011913
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License NumberAPRN11011913
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License NumberAPRN11011913
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: