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General NPI Number Information
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NPI Number | 1184145815
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Entity Type | Organization
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Legal Business Name | SMOKETOWN FAMILY WELLNESS CENTER CORP
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Dates
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Enumeration Date | 07/03/2017
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Last Update Date | 10/10/2023
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Provider Practice Location Address
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Address Line | 760 S HANCOCK ST APT B100
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City | LOUISVILLE
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State | KY
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Zip | 40203-2449
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Country | US
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Telephone | 502-242-7458
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Fax |
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Provider Business Mailing Address
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Address Line | 760 S HANCOCK ST APT B100
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City | LOUISVILLE
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State | KY
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Zip | 40203-2449
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Country | US
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Telephone | 502-242-7458
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Fax | 502-219-3673
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Authorized Official
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Title or Position | PHYSICIAN OWNER
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Name | DR. CHARLOTTE GAY STITES
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Credential | MD
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Telephone | 502-242-7458
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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