MEDICARE: JACQUELINE DEANA SMITH RN,BSN,CCRN,LNC

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	RN173262	OH

General Provider Information

NPI Number	:	1225405293
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE DEANA SMITH RN,BSN,CCRN,LNC

Provider Business Mailing Address
First Line	:	3187 E HUDSON ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43219-1632
Country	:	US
Telephone Number	:	614-599-3203
Fax Number	:

Provider Business Practice Location Address
First Line	:	3187 E HUDSON ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43219-1632
Country	:	US
Telephone Number	:	614-599-3203
Fax Number	:

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

Provider Enumeration Date	:	08/26/2015
Last Update Date	:	08/26/2015

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