Provider Demographics
NPI:1023521317
Name:SMITH, MARY ANN (APRN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:101 JEROME CT
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING
Mailing Address - State:KY
Mailing Address - Zip Code:41076-3522
Mailing Address - Country:US
Mailing Address - Phone:859-781-6273
Mailing Address - Fax:
Practice Address - Street 1:2306 ALEXANDRIA PIKE
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:KY
Practice Address - Zip Code:41071-3234
Practice Address - Country:US
Practice Address - Phone:589-816-0775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010988208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice