Provider Demographics
NPI:1417566142
Name:SMITH, THOMAS J (ACNP)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 RENA ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2012
Mailing Address - Country:US
Mailing Address - Phone:660-342-5295
Mailing Address - Fax:
Practice Address - Street 1:803 RENA ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-2012
Practice Address - Country:US
Practice Address - Phone:660-342-5295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019045891363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2019045891OtherMISSOURI STATE BOARD OF NURSING NURSE PRACTITIONER LICENSE