Provider Demographics
NPI:1982040663
Name:SMITH, CHARNEQUA D (ARNP)
Entity Type:Individual
Prefix:
First Name:CHARNEQUA
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9175 RAMBLEWOOD DR APT 532
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-7066
Mailing Address - Country:US
Mailing Address - Phone:678-360-4401
Mailing Address - Fax:
Practice Address - Street 1:1150 45TH ST
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2361
Practice Address - Country:US
Practice Address - Phone:561-514-5300
Practice Address - Fax:561-514-5538
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9354194363LW0102X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00892400Medicaid