Basic Information
| Provider Information | |||||||||
| NPI: | 1265711170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MARIE | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3700 SOUTHERN BLVD STE 401 | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555002873 | ||||||||
| FaxNumber: | 9372813913 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 W MAIN ST STE 130 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453733384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555002873 | ||||||||
| FaxNumber: | 9379807057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2011 | ||||||||
| LastUpdateDate: | 11/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP1700X | APRN..CNP.12269 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Perinatal | 364S00000X | COA12269NS | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 364SA2200X | RN312421 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health | 363LP0808X | APRNCNP026015 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0083654 | 05 | OH | MEDICAID | COA12269NS | 01 | OH | OHIO LICENSE | OTHER |