Provider Demographics
NPI:1275868630
Name:SMITH, CARLY M (CRNA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:M
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 PEELER ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-2300
Mailing Address - Country:US
Mailing Address - Phone:269-345-8618
Mailing Address - Fax:269-345-1508
Practice Address - Street 1:900 PEELER ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-2300
Practice Address - Country:US
Practice Address - Phone:269-345-8618
Practice Address - Fax:269-345-1508
Is Sole Proprietor?:No
Enumeration Date:2009-10-02
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704244365367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704244365OtherMICHIGAN RN LICENSE