Provider Demographics
NPI:1558878181
Name:SMITH, CHANDRA NICOLE (FNP-C)
Entity Type:Individual
Prefix:MISS
First Name:CHANDRA
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 E. STATE STREET
Mailing Address - Street 2:1ST FLOOR PROMEDICA HOSPICE
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108
Mailing Address - Country:US
Mailing Address - Phone:815-977-9251
Mailing Address - Fax:866-224-1731
Practice Address - Street 1:6000 E. STATE STREET
Practice Address - Street 2:1ST FLOOR PROMEDICA HOSPICE
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108
Practice Address - Country:US
Practice Address - Phone:815-977-9251
Practice Address - Fax:866-224-1731
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.402882163W00000X
IL209.016769363LF0000X
IL277.001193363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse