Provider Demographics
NPI:1134285901
Name:SMITH, SUSAN A (CNM)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8224 PARK LN STE 130
Practice Address - Street 2:VICKERY HEALTH CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-6021
Practice Address - Country:US
Practice Address - Phone:214-266-0266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX522587367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100483006Medicaid
TX100483007Medicaid
TX100483003Medicaid
TX100483005Medicaid
TX100483004Medicaid
TX8Y9217OtherBLUE CROSS BLUE SHIELD
S53323Medicare UPIN
TX100483003Medicaid