MEDICARE: TABETHA LYNN SMITH FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	200923	NC

General Provider Information

NPI Number	:	1043285828
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TABETHA LYNN SMITH FNP-C

Provider Business Mailing Address
First Line	:	3175 WRIGHTSVILLE AVE
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-4184
Country	:	US
Telephone Number	:	910-763-1960
Fax Number	:	910-763-1961

Provider Business Practice Location Address
First Line	:	3175 WRIGHTSVILLE AVE
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-4184
Country	:	US
Telephone Number	:	910-763-1960
Fax Number	:	910-763-1961

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	08/13/2007

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