MEDICARE: MS. NANCY ANN SMITH MSE, LP

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	103T00000X	Psychologist	LP4126	MN
2	103T00000X	Psychologist	323282	MN

General Provider Information

NPI Number	:	1750410783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NANCY ANN SMITH MSE, LP

Provider Business Mailing Address
First Line	:	1013 CEDAR ST
Second Line	:
City	:	WABASSO
State	:	MN
Zip	:	56293-1409
Country	:	US
Telephone Number	:	507-342-2030
Fax Number	:

Provider Business Practice Location Address
First Line	:	1333 MAY ST.
Second Line	:
City	:	WABASSO
State	:	MN
Zip	:	56293
Country	:	US
Telephone Number	:	507-342-7118
Fax Number	:

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

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	07/08/2007

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