Provider Demographics
NPI:1164879110
Name:SMITH, MARY THERESE (BSN, RNC-NIC, IBCLC)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:THERESE
Last Name:SMITH
Suffix:
Gender:F
Credentials:BSN, RNC-NIC, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S ORANGE ST
Mailing Address - Street 2:APT B
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3110
Mailing Address - Country:US
Mailing Address - Phone:610-368-7258
Mailing Address - Fax:
Practice Address - Street 1:205 S ORANGE ST
Practice Address - Street 2:APT B
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-3110
Practice Address - Country:US
Practice Address - Phone:610-368-7258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAL-77562163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant