Provider Demographics
NPI:1467858712
Name:SMITH, GRETA (FNP)
Entity Type:Individual
Prefix:
First Name:GRETA
Middle Name:
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:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-1624
Mailing Address - Fax:
Practice Address - Street 1:9525 GOLD HILL RD
Practice Address - Street 2:
Practice Address - City:SHAWNEETOWN
Practice Address - State:IL
Practice Address - Zip Code:62984-3659
Practice Address - Country:US
Practice Address - Phone:618-269-3815
Practice Address - Fax:618-269-3274
Is Sole Proprietor?:No
Enumeration Date:2014-11-14
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012164363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily