Provider Demographics
NPI:1205473253
Name:SMITH, ERIN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:
Other - Last Name:GLISSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:109 BRECKENRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-7501
Mailing Address - Country:US
Mailing Address - Phone:662-665-5097
Mailing Address - Fax:
Practice Address - Street 1:2580 JACKSON AVE W STE 44
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5497
Practice Address - Country:US
Practice Address - Phone:662-234-9112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903629363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily