Healthcare Provider Details

I. General information

NPI: 1508338856
Provider Name (Legal Business Name): STACY SMITH MSN, RN, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2018
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5345 FM 3 S
MARQUEZ TX
77865-4303
US

IV. Provider business mailing address

5345 FM 3 S
MARQUEZ TX
77865-4303
US

V. Phone/Fax

Practice location:
  • Phone: 979-229-9688
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAP139260
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP139260
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: