Provider Demographics
NPI:1083716450
Name:SMITH, MARTHA (CFNP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 YORK LN
Mailing Address - Street 2:
Mailing Address - City:LIPAN
Mailing Address - State:TX
Mailing Address - Zip Code:76462-1009
Mailing Address - Country:US
Mailing Address - Phone:601-750-2617
Mailing Address - Fax:
Practice Address - Street 1:3801 E US HIGHWAY 377 STE 100
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-7620
Practice Address - Country:US
Practice Address - Phone:817-573-1380
Practice Address - Fax:817-573-1381
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2020-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX913084363LF0000X
MSR678562363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX365622501Medicaid
MS500000361Medicare ID - Type Unspecified
TX365622501Medicaid