Provider Demographics
NPI:1134492291
Name:SMITH, CELESTINE DEMETRICH (ARNP)
Entity type:Individual
Prefix:
First Name:CELESTINE
Middle Name:DEMETRICH
Last Name:SMITH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:CELESTINE
Other - Middle Name:
Other - Last Name:CARSWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP - PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:580 W 8TH ST
Practice Address - Street 2:UFJP - DEPT, OF NEUROSURGERY
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6533
Practice Address - Country:US
Practice Address - Phone:904-244-3950
Practice Address - Fax:904-244-9437
Is Sole Proprietor?:No
Enumeration Date:2012-02-20
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9177923363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003121269AMedicaid
FL0045419-00Medicaid
FL0045419-00Medicaid
FLFV196YMedicare PIN