MEDICARE: MADELINE SMITH RN

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	163W00000X	Registered Nurse	2465600	MN

General Provider Information

NPI Number	:	1043988678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADELINE SMITH RN

Provider Business Mailing Address
First Line	:	3622 GARDEN BLVD N
Second Line	:
City	:	OAKDALE
State	:	MN
Zip	:	55128-3116
Country	:	US
Telephone Number	:	715-338-0880
Fax Number	:

Provider Business Practice Location Address
First Line	:	3622 GARDEN BLVD N
Second Line	:
City	:	OAKDALE
State	:	MN
Zip	:	55128-3116
Country	:	US
Telephone Number	:	715-338-0880
Fax Number	:

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

Provider Enumeration Date	:	08/30/2021
Last Update Date	:	08/30/2021

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