Provider Demographics
NPI:1164720793
Name:SMITH, NANCY (NP-C)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:4485 W STONE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-1050
Practice Address - Country:US
Practice Address - Phone:423-224-3150
Practice Address - Fax:423-224-3169
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15698363L00000X, 364SX0200X
VA0024169265363L00000X, 364SX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I502876Medicare PIN
TN103I500954Medicare PIN
VAV V4739CMedicare PIN
VAV V4739AMedicare PIN