Provider Demographics
NPI:1922065549
Name:SMITH, CARRIE L (CRNA)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:L
Other - Last Name:VANISACKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:740 N MACOMB ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-7813
Mailing Address - Country:US
Mailing Address - Phone:734-240-5238
Mailing Address - Fax:
Practice Address - Street 1:740 N MACOMB ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-7813
Practice Address - Country:US
Practice Address - Phone:734-240-5238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704207344367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4666362Medicaid
MICS207344OtherBLUE CROSS OF MI
MICS207344OtherBLUE CROSS OF MI
MIP00175167Medicare ID - Type UnspecifiedRAILROAD