Provider Demographics
NPI:1336165232
Name:SMITH, LYNETTE S (PHD, PMHNP, FNP)
Entity Type:Individual
Prefix:DR
First Name:LYNETTE
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD, PMHNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2642 CHANDLER DR APT 1814
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-6257
Mailing Address - Country:US
Mailing Address - Phone:812-201-0222
Mailing Address - Fax:
Practice Address - Street 1:2642 CHANDLER DR APT 1814
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-6257
Practice Address - Country:US
Practice Address - Phone:812-021-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007259363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000543710OtherANTHEM PIN
IN200334480AMedicaid
INP39021Medicare UPIN
INTB5110Medicare ID - Type Unspecified
IN200334480AMedicaid