Provider Demographics
NPI:1609086230
Name:SMITH, MARY COLLEEN (FNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:COLLEEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 E NORMAL AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-6110
Mailing Address - Country:US
Mailing Address - Phone:559-497-1610
Mailing Address - Fax:
Practice Address - Street 1:4605 N POLK AVE
Practice Address - Street 2:ROOM 4
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-5334
Practice Address - Country:US
Practice Address - Phone:559-274-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3524111163WC1500X, 163WS0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Not Answered163WS0200XNursing Service ProvidersRegistered NurseSchool
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily