Basic Information
| Provider Information | |||||||||
| NPI: | 1427354919 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | ADRIENNE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 134 S WOODS DR | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329553262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216363066 | ||||||||
| FaxNumber: | 3216362545 | ||||||||
| Practice Location | |||||||||
| Address1: | 699 W COCOA BEACH CSWY STE 401 | ||||||||
| Address2: | |||||||||
| City: | COCOA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217845437 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2011 | ||||||||
| LastUpdateDate: | 10/15/2019 | ||||||||
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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 | 363LP0200X | ARNP 9220199 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | ARNP9220199 | 01 | FL | LICENSE NO. | OTHER | 009579300 | 05 | FL | MEDICAID |