Provider Demographics
NPI:1134450307
Name:SMITH, ROBERT LARRY (FNP-BC)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LARRY
Last Name:SMITH
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5504 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38134-3458
Mailing Address - Country:US
Mailing Address - Phone:901-382-0347
Mailing Address - Fax:
Practice Address - Street 1:260D SHOPPINGWAY BLVD
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-7230
Practice Address - Country:US
Practice Address - Phone:901-303-5040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000014593363LF0000X
ARA005873363LF0000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicaid
TNPENDINGMedicaid