Provider Demographics
NPI:1326289851
Name:SMITH, SANDRA MARIE
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 RELIANCE STREET
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-266-6997
Mailing Address - Fax:
Practice Address - Street 1:50 STRATHMORE CIRCLE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609
Practice Address - Country:US
Practice Address - Phone:585-214-9253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241019-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02388732Medicaid