Provider Demographics
NPI:1184615254
Name:SMITH, AUDREY ANN (CRNP)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5254
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-0254
Mailing Address - Country:US
Mailing Address - Phone:330-506-7514
Mailing Address - Fax:234-254-8026
Practice Address - Street 1:216 TERRA BELLA DR
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-1045
Practice Address - Country:US
Practice Address - Phone:330-506-7514
Practice Address - Fax:234-254-8026
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP06525363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2284960Medicaid
OH9332821Medicare ID - Type Unspecified
OH9332823Medicare ID - Type Unspecified
OH9332822Medicare ID - Type Unspecified