Provider Demographics
NPI:1851480339
Name:SMITH, GWEN (MSN,CNP,CDE)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSN,CNP,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12000 MCCRACKEN RD
Mailing Address - Street 2:SUITE 550
Mailing Address - City:GARFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2964
Mailing Address - Country:US
Mailing Address - Phone:216-663-8686
Mailing Address - Fax:216-663-2153
Practice Address - Street 1:12000 MCCRACKEN RD
Practice Address - Street 2:SUITE 550
Practice Address - City:GARFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2964
Practice Address - Country:US
Practice Address - Phone:216-663-8686
Practice Address - Fax:216-663-2153
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP05426363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2455892Medicaid
OH2455892Medicaid
OHSMNP14881Medicare ID - Type Unspecified