MEDICARE: MADISON SMITH CPNP

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	363LP0200X	Pediatric Nurse Practitioner	0024178866	VA

General Provider Information

NPI Number	:	1669097978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON SMITH CPNP

Provider Business Mailing Address
First Line	:	1220 WYTHE ST APT 258
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-2279
Country	:	US
Telephone Number	:	505-803-2133
Fax Number	:

Provider Business Practice Location Address
First Line	:	1220 WYTHE ST APT 258
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-2279
Country	:	US
Telephone Number	:	505-803-2133
Fax Number	:

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

Provider Enumeration Date	:	06/11/2020
Last Update Date	:	06/11/2020

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