Provider Demographics
NPI:1568027415
Name:SMITH, ELIZABETH JEAN
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38882 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-7875
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:38882 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-7875
Practice Address - Country:US
Practice Address - Phone:440-578-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH173078163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse