MEDICARE: TINA A. SMITH APRN

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	3013143	KY

General Provider Information

NPI Number	:	1073087797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA A. SMITH APRN

Provider Business Mailing Address
First Line	:	638 E COLLEGE AVE STE B
Second Line	:
City	:	STANTON
State	:	KY
Zip	:	40380-2363
Country	:	US
Telephone Number	:	606-318-3500
Fax Number	:	606-318-3506

Provider Business Practice Location Address
First Line	:	638 E COLLEGE AVE STE B
Second Line	:
City	:	STANTON
State	:	KY
Zip	:	40380-2363
Country	:	US
Telephone Number	:	606-318-3500
Fax Number	:	606-318-3503

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

Provider Enumeration Date	:	01/15/2019
Last Update Date	:	10/07/2020

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