MEDICARE: MARY LOU S SMITH N.P.

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	363LW0102X	Women's Health Nurse Practitioner	ARNP9431231	FL
2	363LF0000X	Family Nurse Practitioner	ARNP9431231	FL

General Provider Information

NPI Number	:	1467413237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY LOU S SMITH N.P.

Provider Business Mailing Address
First Line	:	108 YACHT HAVEN DR
Second Line	:
City	:	COCOA BEACH
State	:	FL
Zip	:	32931-2627
Country	:	US
Telephone Number	:	636-346-5002
Fax Number	:

Provider Business Practice Location Address
First Line	:	1840 ELDRON BLVD SE STE 1
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32909-6871
Country	:	US
Telephone Number	:	321-312-4580
Fax Number	:	321-914-4053

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

Provider Enumeration Date	:	03/31/2006
Last Update Date	:	07/21/2022

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