Provider Demographics
NPI:1952067639
Name:SMITH, STEPHANIE SWEET (MSN, PMHNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SWEET
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 KIMEL PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6951
Practice Address - Country:US
Practice Address - Phone:336-718-3550
Practice Address - Fax:336-277-1825
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5015770363L00000X
NC5015770.363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner