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General NPI Number Information
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NPI Number | 1548444011
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Entity Type | Individual
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Provider Name | MARLA RAE SMITH
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Gender | Female
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Dates
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Enumeration Date | 12/20/2007
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Last Update Date | 09/09/2009
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Provider Practice Location Address
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Address Line | 869 NORTH ILLINOIS RT 3
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City | WATERLOO
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State | IL
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Zip | 62298
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Country | US
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Telephone | 618-939-7771
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Fax | 618-939-7746
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Provider Business Mailing Address
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Address Line | 519 COVINGTON DRIVE
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City | WATERLOO
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State | IL
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Zip | 62298-3296
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number | 152008
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number | 209007742
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License Number State | IL
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