Provider Demographics
NPI:1487225520
Name:SMITH, EUGENIA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:EUGENIA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32556 FIRWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-1544
Mailing Address - Country:US
Mailing Address - Phone:248-497-6507
Mailing Address - Fax:
Practice Address - Street 1:400 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2136
Practice Address - Country:US
Practice Address - Phone:877-929-6342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3704241370363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3704241370OtherAPRN LICENSE