Provider Demographics
NPI:1164771614
Name:SMITH, VINCENT ROSS (DNP, ANP-C)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:ROSS
Last Name:SMITH
Suffix:
Gender:M
Credentials:DNP, ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 SPRINGER DR
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6413
Mailing Address - Country:US
Mailing Address - Phone:708-634-4602
Mailing Address - Fax:
Practice Address - Street 1:311 E 89TH AVE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-8162
Practice Address - Country:US
Practice Address - Phone:219-769-7062
Practice Address - Fax:630-495-1770
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28250476A363LA2200X
FLRN9310400163W00000X
NVRN80537163W00000X
CANP 22695363LA2200X
NVAPRN001802363LA2200X
CARN 805484163W00000X
IN71008935A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
INMCO300042636Medicaid