Provider Demographics
NPI:1740575075
Name:SMITH, DERAINEY R (FNP)
Entity Type:Individual
Prefix:
First Name:DERAINEY
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 HIGHWAY 62 EAST
Mailing Address - Street 2:
Mailing Address - City:YELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72687-2580
Mailing Address - Country:US
Mailing Address - Phone:870-449-9355
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:437 HIGHWAY 62 EAST
Practice Address - Street 2:
Practice Address - City:YELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72687-4603
Practice Address - Country:US
Practice Address - Phone:870-449-9355
Practice Address - Fax:870-423-7178
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA003560363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR188545758Medicaid
AR188545758Medicaid