Provider Demographics
NPI:1750047635
Name:SMITH, NICOLE SHERAE (DNP, CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SHERAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:PROSPECT PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19076-2302
Mailing Address - Country:US
Mailing Address - Phone:215-990-8232
Mailing Address - Fax:
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19111-2434
Practice Address - Country:US
Practice Address - Phone:267-990-1028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN615430367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered