Provider Demographics
NPI:1396365714
Name:SMITH, MARYJO (RN)
Entity Type:Individual
Prefix:
First Name:MARYJO
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:LUSBY
Mailing Address - State:MD
Mailing Address - Zip Code:20657-2714
Mailing Address - Country:US
Mailing Address - Phone:410-474-2032
Mailing Address - Fax:240-718-1709
Practice Address - Street 1:234 HARBOR DR
Practice Address - Street 2:
Practice Address - City:LUSBY
Practice Address - State:MD
Practice Address - Zip Code:20657-2714
Practice Address - Country:US
Practice Address - Phone:410-474-2032
Practice Address - Fax:240-718-1709
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR076273163WX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0106XNursing Service ProvidersRegistered NurseOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR076273OtherNURSING LICENSE