Healthcare Provider Details

I. General information

NPI: 1679220974
Provider Name (Legal Business Name): CAROLYN SMITH MSN, APRN, CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2022
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5503 SHOAL CREEK BLVD
AUSTIN TX
78756-1802
US

IV. Provider business mailing address

5503 SHOAL CREEK BLVD
AUSTIN TX
78756-1802
US

V. Phone/Fax

Practice location:
  • Phone: 512-689-4941
  • Fax:
Mailing address:
  • Phone: 512-689-4941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number776121
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number20188142
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: