Healthcare Provider Details

I. General information

NPI: 1285631648
Provider Name (Legal Business Name): BOBBIE J SMITH-EDE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 BLACK OAK DRIVE
MEDFORD OR
97504-8225
US

IV. Provider business mailing address

2825 E BARNETT RD MSS
MEDFORD OR
97504-8332
US

V. Phone/Fax

Practice location:
  • Phone: 541-789-8000
  • Fax: 541-789-8225
Mailing address:
  • Phone: 541-789-4281
  • Fax: 541-789-4806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number200250183
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number200250183NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: