Healthcare Provider Details

I. General information

NPI: 1982250064
Provider Name (Legal Business Name): MARCIE SMITH-CORLETTE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARCIE SMITH-CORLETTE NURSE PRACTITIONER

II. Dates (important events)

Enumeration Date: 08/14/2019
Last Update Date: 11/16/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12221 MERIT DR STE 450
DALLAS TX
75251-2294
US

IV. Provider business mailing address

12221 MERIT DR STE 450
DALLAS TX
75251-2294
US

V. Phone/Fax

Practice location:
  • Phone: 972-770-1032
  • Fax: 469-484-2126
Mailing address:
  • Phone: 972-770-1032
  • Fax: 469-484-2126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP141979
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: