Basic Information
| Provider Information | |||||||||
| NPI: | 1336156587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | PROF. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP/PMH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PILOTTI | ||||||||
| OtherFirstName: | PATRICIA | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5158 ORCHARD GRN | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210451930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108252281 | ||||||||
| FaxNumber: | 4108250757 | ||||||||
| Practice Location | |||||||||
| Address1: | 1407 YORK RD | ||||||||
| Address2: | SUITE 309 | ||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210936097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108252281 | ||||||||
| FaxNumber: | 4108250757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R39655 | MD | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | R39655 | MD | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | MS1277260 | 01 | MD | DEA | OTHER | 361LE325 | 05 | MD | MEDICAID | N57763 | 01 | MD | CDS | OTHER | 010736J69 | 05 | MD | MEDICAID |