Basic Information
| Provider Information | |||||||||
| NPI: | 1225004377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MARYELLEN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CENTRACARE CIR #1300 | ||||||||
| Address2: | CENTRACARE CLINIC - WOMEN'S AND CHILDRENS | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543610 | ||||||||
| FaxNumber: | 9528835395 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CENTRACARE CIR #1300 | ||||||||
| Address2: | CENTRACARE CLINIC - WOMEN'S AND CHILDRENS | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543610 | ||||||||
| FaxNumber: | 6517025305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 09/07/2011 | ||||||||
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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 | 363L00000X | 0735016 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | R073501-6 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 071742800 | 05 | MN | MEDICAID |