Provider Demographics
NPI:1255766366
Name:SMITH, MARY KAY (RN, IBCLC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KAY
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2878 RIVER MEADOW CIR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2333
Mailing Address - Country:US
Mailing Address - Phone:734-645-7952
Mailing Address - Fax:
Practice Address - Street 1:2878 RIVER MEADOW CIR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-2333
Practice Address - Country:US
Practice Address - Phone:734-645-7952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704239518163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse