Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LG0600X | Nurse Practitioner - Gerontology | 26NJ00148300 | NJ |
Y | 363LG0600X | Nurse Practitioner - Gerontology | F340605-1 | NY |
NPI | 1053533208 |
---|---|
Provider Name | Ms. Melissa Smith |
First Address | New York, NY 10119-0899 |
Second Address | New York, NY 10119-0899 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2007 |
Last Update Date | 11/06/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F340605 | NYS GNP LICENSE (01) | NY |
MS1133824 | NYS DEA (01) | NY |