Provider Demographics
NPI:1225004377
Name:SMITH, MARYELLEN T (CPNP)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:T
Last Name:SMITH
Suffix:
Gender:F
Credentials:CPNP
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Mailing Address - Street 1:1900 CENTRACARE CIR #1300
Mailing Address - Street 2:CENTRACARE CLINIC - WOMEN'S AND CHILDRENS
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-654-3610
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:1900 CENTRACARE CIR #1300
Practice Address - Street 2:CENTRACARE CLINIC - WOMEN'S AND CHILDRENS
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-654-3610
Practice Address - Fax:651-702-5305
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2011-09-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN0735016363L00000X
MNR073501-6363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN071742800Medicaid
MN071742800Medicaid
P03829Medicare UPIN