MEDICARE: EBONY MICHAELA SMITH WHNP

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	905954	MS
2	363LW0102X	Women's Health Nurse Practitioner	18029	TN

General Provider Information

NPI Number	:	1487082699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY MICHAELA SMITH WHNP

Provider Business Mailing Address
First Line	:	965 RIDGE LAKE BLVD STE 315
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38120-9401
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	61 BROADWAY, STE 1313
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10006-2754
Country	:	US
Telephone Number	:	914-919-9200
Fax Number	:

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

Provider Enumeration Date	:	10/25/2013
Last Update Date	:	11/26/2024

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