Basic Information
| Provider Information | |||||||||
| NPI: | 1982040663 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CHARNEQUA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9175 RAMBLEWOOD DR APT 532 | ||||||||
| Address2: | |||||||||
| City: | CORAL SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330717066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783604401 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1150 45TH ST | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334072361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615145300 | ||||||||
| FaxNumber: | 5615145538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2013 | ||||||||
| LastUpdateDate: | 08/15/2017 | ||||||||
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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 | ARNP9354194 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LA2200X | ARNP9354194 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 00892400 | 05 | FL | MEDICAID |