Basic Information
| Provider Information | |||||||||
| NPI: | 1093072415 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | APRN, NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HITCHCOCK WAY | ||||||||
| Address2: | PEDIATRIC ENDOCRINOLOGY | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036952790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 HITCHCOCK WAY | ||||||||
| Address2: | PEDIATRIC ENDOCRINOLOGY | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036952790 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2012 | ||||||||
| LastUpdateDate: | 05/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 050915-23 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3100525 | 05 | NH | MEDICAID |