Basic Information
| Provider Information | |||||||||
| NPI: | 1093759524 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | LORELLE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11479 CORTEZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346137367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525973511 | ||||||||
| FaxNumber: | 3525973466 | ||||||||
| Practice Location | |||||||||
| Address1: | 11479 CORTEZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346137367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525973511 | ||||||||
| FaxNumber: | 3525973466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 08/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | RN2727382 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | ARNP2727382 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | FL | MEDICAID |