Healthcare Provider Details

I. General information

NPI: 1710384896
Provider Name (Legal Business Name): EDMUNDO SMITH FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1126 HARTFORD AVE
JOHNSTON RI
02919-7109
US

IV. Provider business mailing address

1126 HARTFORD AVE
JOHNSTON RI
02919-7109
US

V. Phone/Fax

Practice location:
  • Phone: 401-519-1940
  • Fax: 401-351-6613
Mailing address:
  • Phone: 401-519-1940
  • Fax: 401-351-6613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN276874
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberETL01150
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN02389
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: