=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689192767
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CANDREA SMITH FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2017
-----------------------------------------------------
Last Update Date | 09/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 504 LEWIS ST
-----------------------------------------------------
City | HAVRE DE GRACE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21078-3420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-502-5311
-----------------------------------------------------
Fax | 443-955-5736
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 612 HEATHLAND TRL
-----------------------------------------------------
City | ABERDEEN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21001-3651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-570-8289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | R184963
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------