Healthcare Provider Details

I. General information

NPI: 1184020554
Provider Name (Legal Business Name): TYREE DARNELL SMITH MSN, CRNP, CPNP-AC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2014
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 STREET AND CIVIC CENTER BLVD 1ST FLOOR WOOD BUILDING
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

1609 MERRIBROOK LN
PHILADELPHIA PA
19151-2717
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-3440
  • Fax:
Mailing address:
  • Phone: 215-888-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberSP014445
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberSP014445
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberSP014445
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: