Healthcare Provider Details

I. General information

NPI: 1790725083
Provider Name (Legal Business Name): MERYLE DOROTHY SMITH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 W LAMPASAS ST
ENNIS TX
75119-4535
US

IV. Provider business mailing address

PO BOX 140430
DALLAS TX
75214-0430
US

V. Phone/Fax

Practice location:
  • Phone: 972-875-0900
  • Fax:
Mailing address:
  • Phone: 214-522-0210
  • Fax: 214-522-0474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number514500
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: