Healthcare Provider Details

I. General information

NPI: 1053789123
Provider Name (Legal Business Name): PAMELA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 02/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7630 SOUTHERN BLVD
YOUNGSTOWN OH
44512-5633
US

IV. Provider business mailing address

7630 SOUTHERN BLVD
YOUNGSTOWN OH
44512-5633
US

V. Phone/Fax

Practice location:
  • Phone: 330-729-8011
  • Fax: 330-729-8084
Mailing address:
  • Phone: 330-729-8011
  • Fax: 330-729-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCOA.17670-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: