Provider Demographics
NPI:1285043745
Name:SMITH, ZACHARY EDWARD (LPN)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:EDWARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 OTSEGO ST
Mailing Address - Street 2:
Mailing Address - City:ILION
Mailing Address - State:NY
Mailing Address - Zip Code:13357-2512
Mailing Address - Country:US
Mailing Address - Phone:315-868-0670
Mailing Address - Fax:
Practice Address - Street 1:358 OTSEGO ST
Practice Address - Street 2:
Practice Address - City:ILION
Practice Address - State:NY
Practice Address - Zip Code:13357-2512
Practice Address - Country:US
Practice Address - Phone:315-868-0670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-09
Last Update Date:2014-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY318993-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse