Provider Demographics
NPI:1033185269
Name:SMITH, WANDA L (CRNA)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:LOU
Other - Last Name:BOYD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:44 BENTWATER CIR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-7646
Mailing Address - Country:US
Mailing Address - Phone:561-649-1932
Mailing Address - Fax:
Practice Address - Street 1:1613 HARRISON PKWY
Practice Address - Street 2:#200
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2853
Practice Address - Country:US
Practice Address - Phone:954-838-2371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3356972367500000X
VA0024135734367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305202030Medicaid
FL305202030Medicaid
R74774Medicare UPIN
VAQ38937AMedicare PIN
FLG2578WMedicare ID - Type Unspecified