Provider Demographics
NPI:1184207276
Name:SMITH, MADDISON K (FNP-BC)
Entity type:Individual
Prefix:
First Name:MADDISON
Middle Name:K
Last Name:SMITH
Suffix:
Gender:
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 1:1 FORD PL STE 3A
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:
Practice Address - Street 1:71050 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:BRUCE TWP
Practice Address - State:MI
Practice Address - Zip Code:48065-3898
Practice Address - Country:US
Practice Address - Phone:586-277-0244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704326587NSA21098363LP2300X
MI4704326587363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care