Basic Information
| Provider Information | |||||||||
| NPI: | 1225775729 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | LEANNE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 69 WHISPERING PINE DR | ||||||||
| Address2: | |||||||||
| City: | PALM COAST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321647294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3868714491 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1630 MASON AVE | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321174500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862389064 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2022 | ||||||||
| LastUpdateDate: | 07/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 11019694 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 9314399 | FL | N | Nursing Service Providers | Registered Nurse | 363L00000X | APRN11019694 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | MS7333216 | 01 | DEA | OTHER |