Provider Demographics
NPI:1609054378
Name:SMITH, VEVIAN D (NP)
Entity Type:Individual
Prefix:
First Name:VEVIAN
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:12171 SW 268TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-8001
Mailing Address - Country:US
Mailing Address - Phone:305-278-0200
Mailing Address - Fax:786-430-1583
Practice Address - Street 1:11211 N NEBRASKA AVE STE A5
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-5767
Practice Address - Country:US
Practice Address - Phone:813-514-2333
Practice Address - Fax:813-482-0015
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 2747462363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308960600Medicaid
FLPENDINGMedicaid
FLAI945ZMedicare PIN