Provider Demographics
NPI:1417263633
Name:SMITH, SHERRY (APRN)
Entity Type:Individual
Prefix:MS
First Name:SHERRY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:SHERRY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:3513 KEARLY AVE
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33875-4613
Mailing Address - Country:US
Mailing Address - Phone:850-867-2861
Mailing Address - Fax:
Practice Address - Street 1:2043 S NEIL ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7219
Practice Address - Country:US
Practice Address - Phone:309-655-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004057363LF0000X
IL209011716363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid