Provider Demographics
NPI:1043854268
Name:SMITH, CHELSEA MARIE
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHELSEA
Other - Middle Name:MARIE
Other - Last Name:AUSTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:106 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:CHITTENANGO
Mailing Address - State:NY
Mailing Address - Zip Code:13037-1703
Mailing Address - Country:US
Mailing Address - Phone:315-706-8974
Mailing Address - Fax:
Practice Address - Street 1:159 W 1ST ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2045
Practice Address - Country:US
Practice Address - Phone:315-342-9575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY174400000XMedicaid