Provider Demographics
NPI:1437882388
Name:SMITH, ANDREA LYN (RN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYN
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4995 BRADENTON AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-3551
Mailing Address - Country:US
Mailing Address - Phone:614-580-6917
Mailing Address - Fax:614-368-1357
Practice Address - Street 1:4995 BRADENTON AVE STE 130
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3551
Practice Address - Country:US
Practice Address - Phone:614-580-6917
Practice Address - Fax:614-368-1357
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.406371163W00000X
OHAPRN.CNP.0031735363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0495853Medicaid