Basic Information
| Provider Information | |||||||||
| NPI: | 1609054378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | VEVIAN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12171 SW 268TH ST | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330328001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052780200 | ||||||||
| FaxNumber: | 7864301583 | ||||||||
| Practice Location | |||||||||
| Address1: | 11211 N NEBRASKA AVE STE A5 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336125767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135142333 | ||||||||
| FaxNumber: | 8134820015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2008 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 363L00000X | ARNP 2747462 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 308960600 | 05 | FL | MEDICAID | PENDING | 05 | FL | MEDICAID |