Provider Demographics
NPI:1801371745
Name:SMITH-COLLINGTON, MARY M (CNA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:M
Last Name:SMITH-COLLINGTON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 882011
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34988-2011
Mailing Address - Country:US
Mailing Address - Phone:772-940-2028
Mailing Address - Fax:
Practice Address - Street 1:542 NW ARCHER AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-1076
Practice Address - Country:US
Practice Address - Phone:772-940-2028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0000OtherPRIVATE