Provider Demographics
NPI:1639763261
Name:SMITH, ALLISON TYLER
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:TYLER
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 1:13160 CORBEL CIR APT 625
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-7891
Mailing Address - Country:US
Mailing Address - Phone:954-628-2454
Mailing Address - Fax:
Practice Address - Street 1:13160 CORBEL CIR APT 625
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7891
Practice Address - Country:US
Practice Address - Phone:954-625-2454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9412359163WC0200X
TX1045666367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine