Healthcare Provider Details

I. General information

NPI: 1134202708
Provider Name (Legal Business Name): MYRTLE A SMITH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MACCORKLE AVE SE
CHARLESTON WV
25304
US

IV. Provider business mailing address

618 EVEREST CIRCLE
ST ALBANS WV
29177
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-4077
  • Fax: 304-388-9852
Mailing address:
  • Phone: 304-722-3559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number21661
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number29741
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: