Healthcare Provider Details

I. General information

NPI: 1164139168
Provider Name (Legal Business Name): SHELBY REBECCA SMART RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 INTREPID AVE
PHILADELPHIA PA
19112-1229
US

IV. Provider business mailing address

6642 BITTNERS CORNER RD
NEW TRIPOLI PA
18066-2519
US

V. Phone/Fax

Practice location:
  • Phone: 864-764-0322
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number95294467
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: