Provider Demographics
NPI:1730493966
Name:SMITH, BRENDA RENAYE
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:RENAYE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:THORNTON
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:402 MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-5326
Mailing Address - Country:US
Mailing Address - Phone:318-338-3540
Mailing Address - Fax:318-338-3542
Practice Address - Street 1:402 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5326
Practice Address - Country:US
Practice Address - Phone:318-338-3540
Practice Address - Fax:318-338-3542
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06154363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily