Basic Information
| Provider Information | |||||||||
| NPI: | 1710384896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | EDMUNDO | ||||||||
| MiddleName: | |||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1126 HARTFORD AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029197109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015191940 | ||||||||
| FaxNumber: | 4013516613 | ||||||||
| Practice Location | |||||||||
| Address1: | 1126 HARTFORD AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029197109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015191940 | ||||||||
| FaxNumber: | 4013516613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2014 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN276874 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN02389 | RI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | ETL01150 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.