Basic Information
| Provider Information | |||||||||
| NPI: | 1770928343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | SHAFONNE | ||||||||
| MiddleName: | MONIQUE | ||||||||
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| Credential: | WHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 HOLLY HILLS AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631112410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143535190 | ||||||||
| FaxNumber: | 3143537631 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 HOLLY HILLS AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631112410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143535190 | ||||||||
| FaxNumber: | 3143537631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2013 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 2016009888 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LW0102X | 28208566A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LA2200X | 2016009888 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.