Provider Demographics
NPI:1114587474
Name:SMOTHERS, SHAQUANTALIA (FNP)
Entity Type:Individual
Prefix:
First Name:SHAQUANTALIA
Middle Name:
Last Name:SMOTHERS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:952 FOUNTAIN PL
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-3100
Mailing Address - Country:US
Mailing Address - Phone:708-359-5071
Mailing Address - Fax:
Practice Address - Street 1:852 S WEST ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6400
Practice Address - Country:US
Practice Address - Phone:630-305-5027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041418910363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily