Provider Demographics
NPI:1720029838
Name:SMITH, LORETTA (APN)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:LORETTA
Other - Middle Name:
Other - Last Name:CZARNECKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-556-7717
Mailing Address - Fax:573-556-7723
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-556-7717
Practice Address - Fax:573-556-7723
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO152411363L00000X
MNR 103113-3363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00192762OtherMEDICARE RAILROAD
MO423931724Medicaid
MOCD6059OtherRAILROAD GROUP
MO437082OtherHEALTHLINK
MO423931724Medicaid
MO823703715Medicare PIN