Provider Demographics
NPI:1114989274
Name:SMITH, ERNESTINE (NP)
Entity Type:Individual
Prefix:MS
First Name:ERNESTINE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42TH MED GROUP
Mailing Address - Street 2:300 SOUTH TWINING STREET
Mailing Address - City:MAXWELL AIR FORCE BASE
Mailing Address - State:AL
Mailing Address - Zip Code:36112
Mailing Address - Country:US
Mailing Address - Phone:334-953-7824
Mailing Address - Fax:
Practice Address - Street 1:42 MED GROUP
Practice Address - Street 2:300 SOUTH TWINING
Practice Address - City:MAXWELL AIR FORCE BASE
Practice Address - State:AL
Practice Address - Zip Code:36112
Practice Address - Country:US
Practice Address - Phone:334-953-7824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01457ANP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health