=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568813061
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAVIA NIKOL SMITH FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2016
-----------------------------------------------------
Last Update Date | 06/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11133 DUNN RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63136-6163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-653-5700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10511 ROSETON CT
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63114-1957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-420-2768
-----------------------------------------------------
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 | 2015019119
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------