Provider Demographics
NPI:1619429610
Name:SMITH, MADISON CLAIRE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:CLAIRE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30177 PINECREST DR
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:KS
Mailing Address - Zip Code:66083-6078
Mailing Address - Country:US
Mailing Address - Phone:913-991-3711
Mailing Address - Fax:
Practice Address - Street 1:30177 PINECREST DR.
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:KS
Practice Address - Zip Code:66083
Practice Address - Country:US
Practice Address - Phone:913-991-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSK02-91-8930390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program