Basic Information
| Provider Information | |||||||||
| NPI: | 1619128360 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 N SHACKLEFORD RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722112840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017122571 | ||||||||
| FaxNumber: | 5014047789 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 N SHACKLEFORD RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722112840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017122571 | ||||||||
| FaxNumber: | 5014047789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA-359 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.