Basic Information
| Provider Information | |||||||||
| NPI: | 1700214525 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | EBONY | ||||||||
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| Credential: | WHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 OPELOUSAS ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706012641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374939983 | ||||||||
| FaxNumber: | 3373101161 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 PATTERSON ST | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705011849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374399983 | ||||||||
| FaxNumber: | 3373101161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2013 | ||||||||
| LastUpdateDate: | 06/09/2016 | ||||||||
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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 | 363LW0102X | 07542 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 2350706 | 05 | LA | MEDICAID |