Provider Demographics
NPI:1558873653
Name:SMITH, MANDY (NP)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 MILL END CT
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-8986
Mailing Address - Country:US
Mailing Address - Phone:252-338-5183
Mailing Address - Fax:252-338-5669
Practice Address - Street 1:104 MILL END CT
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-8986
Practice Address - Country:US
Practice Address - Phone:252-338-5183
Practice Address - Fax:252-338-5669
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC239523363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health