=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053091199
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. MONTRAY SMITH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2023
-----------------------------------------------------
Last Update Date | 10/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 ABRAHAM FLEXNER WAY STE 1200
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-3841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-721-5899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 633 E DAISY LN
-----------------------------------------------------
City | NEW ALBANY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47150-4482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-207-3911
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 0033120
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 3018302
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------