Provider Demographics
NPI:1639373483
Name:SMITH, SUSAN J (RNC FNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:RNC FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3318
Mailing Address - Country:US
Mailing Address - Phone:573-339-0909
Mailing Address - Fax:
Practice Address - Street 1:1500 N WESTWOOD BLVD
Practice Address - Street 2:BOX 658
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3318
Practice Address - Country:US
Practice Address - Phone:573-339-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108177363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425270931Medicaid
MO425270907Medicaid
MO425270956Medicaid
MO425270923Medicaid
MO425270949Medicaid