Provider Demographics
NPI:1356342984
Name:SMITH, SANDRA L (APRN, FNP-BC)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN, FNP-BC
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 20
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45327-0020
Mailing Address - Country:US
Mailing Address - Phone:727-426-0826
Mailing Address - Fax:
Practice Address - Street 1:4348 SOUTHPOINT BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-0903
Practice Address - Country:US
Practice Address - Phone:904-281-1915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.08269363LF0000X
OHCOA.08269-NP363LF0000X, 363LP2300X
FLARNP9477015363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024558600Medicaid
OH2576636Medicaid
OHQ44722Medicare UPIN