Provider Demographics
NPI:1659736247
Name:SMITH, NICOLE PRIMA (CRNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:PRIMA
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 CIVIC CENTER BLVD
Mailing Address - Street 2:3 WEST
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5127
Mailing Address - Country:US
Mailing Address - Phone:215-615-0063
Mailing Address - Fax:215-349-8144
Practice Address - Street 1:3400 CIVIC CENTER BLVD
Practice Address - Street 2:3 WEST
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5127
Practice Address - Country:US
Practice Address - Phone:215-615-0063
Practice Address - Fax:215-349-8144
Is Sole Proprietor?:No
Enumeration Date:2015-12-23
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340199363LF0000X, 363LF0000X
PASP017571363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily