Basic Information
| Provider Information | |||||||||
| NPI: | 1164720793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 105 W STONE DR | ||||||||
| Address2: | SUITE 6A | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234087220 | ||||||||
| FaxNumber: | 4234087405 | ||||||||
| Practice Location | |||||||||
| Address1: | 4485 W STONE DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376601050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243150 | ||||||||
| FaxNumber: | 4232243169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2011 | ||||||||
| LastUpdateDate: | 04/27/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 15698 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 0024169265 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364SX0200X | 0024169265 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Oncology | 364SX0200X | 15698 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Oncology |
No ID Information.