Provider Demographics
NPI:1760507610
Name:SMITH, MARTHA DELLE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:DELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 VALENCIA TER
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-3312
Mailing Address - Country:US
Mailing Address - Phone:404-357-1612
Mailing Address - Fax:
Practice Address - Street 1:1818 ALBION ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37208-2918
Practice Address - Country:US
Practice Address - Phone:404-357-1612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12378367500000X
NC240346367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3600064Medicaid
KY7100012730OtherKY MEDICAID
TN36000641Medicaid
TN4155771OtherBCBS
NC8053870Medicaid
SCNAN973Medicaid
TN3600064Medicaid
TN4155771OtherBCBS
SCNAN973Medicaid