MEDICARE: MRS. SUE M SMITH M.S.R.N.C.,CNS

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	RN-191200	OH

General Provider Information

NPI Number	:	1609816446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUE M SMITH M.S.R.N.C.,CNS

Provider Business Mailing Address
First Line	:	PO BOX 4670
Second Line	:
City	:	NEWARK
State	:	OH
Zip	:	43058-4670
Country	:	US
Telephone Number	:	740-522-8477
Fax Number	:	740-788-3424

Provider Business Practice Location Address
First Line	:	8402 BLACKJACK ROAD EXT
Second Line	:
City	:	MOUNT VERNON
State	:	OH
Zip	:	43050-9193
Country	:	US
Telephone Number	:	740-397-0442
Fax Number	:	740-788-3424

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

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	04/22/2011

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