Provider Demographics
NPI:1659055838
Name:SMITH, DEZARE JOCLYN (APRN)
Entity Type:Individual
Prefix:
First Name:DEZARE
Middle Name:JOCLYN
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN
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 2
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-0002
Mailing Address - Country:US
Mailing Address - Phone:937-489-7770
Mailing Address - Fax:
Practice Address - Street 1:243 VINCENT AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-3949
Practice Address - Country:US
Practice Address - Phone:937-489-7770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0034026363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily