Provider Demographics
NPI:1598310740
Name:SMITH, MARY JANE (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29653 ANCHOR CROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-9594
Mailing Address - Country:US
Mailing Address - Phone:251-625-6896
Mailing Address - Fax:
Practice Address - Street 1:3750 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-5407
Practice Address - Country:US
Practice Address - Phone:251-460-0999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-112783363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL245903Medicaid
ALP02453396OtherRAILROAD MEDICARE
AL246049Medicaid
ALA871121VOtherMEDICARE PTAN
AL248711Medicaid