Provider Demographics
NPI:1194821793
Name:SMOCK, MANDY RACHELLE (BSN, RN)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:RACHELLE
Last Name:SMOCK
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2327 NE SMOKEY HILL DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-7019
Mailing Address - Country:US
Mailing Address - Phone:816-246-2047
Mailing Address - Fax:816-246-2047
Practice Address - Street 1:2327 NE SMOKEY HILL DR
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-7019
Practice Address - Country:US
Practice Address - Phone:816-246-2047
Practice Address - Fax:816-246-2047
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO131015163WC0400X
KS14-86320-101163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management