Provider Demographics
NPI:1083099568
Name:SMITH, MANDESA MALIKA (CNM)
Entity Type:Individual
Prefix:MRS
First Name:MANDESA
Middle Name:MALIKA
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNM
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Other - Credentials:
Mailing Address - Street 1:5221 PARAMOUNT PKWY STE 220
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-5490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4300 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358
Practice Address - Country:US
Practice Address - Phone:910-608-3078
Practice Address - Fax:910-608-3079
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC249148163WM0102X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC573OtherLICENSE NUMBER