Provider Demographics
NPI:1811380926
Name:SMITH, SAMANTHA (FNP-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PHYSICIANS WAY STE 111
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37090-8131
Mailing Address - Country:US
Mailing Address - Phone:615-449-0990
Mailing Address - Fax:615-449-4835
Practice Address - Street 1:101 PHYSICIANS WAY STE 111
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37090
Practice Address - Country:US
Practice Address - Phone:615-449-0990
Practice Address - Fax:615-449-4835
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19639363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ016413Medicaid