Provider Demographics
NPI:1356672604
Name:SMITH, THERESA MONAHAN (RN, CNP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MONAHAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:D
Other - Last Name:MONAHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:177 CARROLL AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-6315
Mailing Address - Country:US
Mailing Address - Phone:508-510-5133
Mailing Address - Fax:508-583-9800
Practice Address - Street 1:177 CARROLL AVE
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-6315
Practice Address - Country:US
Practice Address - Phone:508-510-5133
Practice Address - Fax:508-583-9800
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA115563163WP0808X
MARN115563363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11002802513OtherMASS HEALTH