Provider Demographics
NPI:1265711170
Name:SMITH, MARIE NICOLE (RN, CNS)
Entity type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:
Credentials:RN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 SOUTHERN BLVD STE 401
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1265
Mailing Address - Country:US
Mailing Address - Phone:855-500-2873
Mailing Address - Fax:937-281-3913
Practice Address - Street 1:600 W MAIN ST STE 130
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-3384
Practice Address - Country:US
Practice Address - Phone:855-500-2873
Practice Address - Fax:937-980-7057
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRNCNP026015363LP0808X, 364SP0808X
OHAPRN..CNP.12269363LP1700X
OHCOA12269NS364S00000X
OHRN312421364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP1700XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPerinatal
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCOA12269NSOtherOHIO LICENSE
OH0083654Medicaid
OH0083654Medicaid