Provider Demographics
NPI:1417204025
Name:SMITH, MELANIE R (FNP)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 JOHNSTOWN DR
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65742-9366
Mailing Address - Country:US
Mailing Address - Phone:417-753-7770
Mailing Address - Fax:
Practice Address - Street 1:199 JOHNSTOWN DR
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65742-9366
Practice Address - Country:US
Practice Address - Phone:417-753-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012028206363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MOPENDINGMedicare PIN