Provider Demographics
NPI:1467413237
Name:SMITH, MARY LOU S (NP)
Entity Type:Individual
Prefix:
First Name:MARY LOU
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:108 YACHT HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-2627
Mailing Address - Country:US
Mailing Address - Phone:636-346-5002
Mailing Address - Fax:
Practice Address - Street 1:1840 ELDRON BLVD SE STE 1
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-6871
Practice Address - Country:US
Practice Address - Phone:321-312-4580
Practice Address - Fax:321-914-4053
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLARNP9431231363LW0102X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOQ10272Medicare UPIN
MO819430556Medicare ID - Type Unspecified