Basic Information
| Provider Information | |||||||||
| NPI: | 1023761905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MINDY | ||||||||
| MiddleName: | ALLISON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REICH | ||||||||
| OtherFirstName: | MINDY | ||||||||
| OtherMiddleName: | ALLISON | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 153 RIDGE TOP RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290727131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033164962 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 131 SUNSET CT | ||||||||
| Address2: | |||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291692429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037962222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2022 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 25442 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363L00000X | 25442 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.