Provider Demographics
NPI:1609226422
Name:SMITH, CHESTER CORY (PHD, NP-C)
Entity Type:Individual
Prefix:
First Name:CHESTER
Middle Name:CORY
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 BROAD AVE
Mailing Address - Street 2:STE 300A
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2404
Mailing Address - Country:US
Mailing Address - Phone:228-575-2700
Mailing Address - Fax:228-575-2710
Practice Address - Street 1:1509 DULLES DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-3718
Practice Address - Country:US
Practice Address - Phone:337-408-0815
Practice Address - Fax:337-991-9288
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901546363LP2300X
ARA004768363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care