Provider Demographics
NPI:1609816446
Name:SMITH, SUE M (MSRNC,CNS)
Entity Type:Individual
Prefix:MRS
First Name:SUE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSRNC,CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4670
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43058-4670
Mailing Address - Country:US
Mailing Address - Phone:740-522-8477
Mailing Address - Fax:740-788-3424
Practice Address - Street 1:8402 BLACKJACK ROAD EXT
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-9193
Practice Address - Country:US
Practice Address - Phone:740-397-0442
Practice Address - Fax:740-788-3424
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-191200363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health