Basic Information
| Provider Information | |||||||||
| NPI: | 1376554303 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | RUARK | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 FRONT AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210935364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102967190 | ||||||||
| FaxNumber: | 4439917768 | ||||||||
| Practice Location | |||||||||
| Address1: | 8 DENTON PLZ | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216299501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4436062300 | ||||||||
| FaxNumber: | 4436062305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 11/08/2017 | ||||||||
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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 | 363LF0000X | R073073 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.