Basic Information
| Provider Information | |||||||||
| NPI: | 1326388695 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JOHANNA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 MARCUS AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110421113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166226040 | ||||||||
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| Practice Location | |||||||||
| Address1: | 410 HALLOCK AVE | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117761232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316421100 | ||||||||
| FaxNumber: | 6316421190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2013 | ||||||||
| LastUpdateDate: | 02/25/2013 | ||||||||
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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 | 363LA2200X | 306296 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.