Provider Demographics
NPI:1669909560
Name:SMITH, DOREEN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MISS
First Name:DOREEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 OLD RIVERHEAD ROAD
Mailing Address - Street 2:
Mailing Address - City:WESTHAMPTON BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11946
Mailing Address - Country:US
Mailing Address - Phone:631-369-4292
Mailing Address - Fax:
Practice Address - Street 1:300 E MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2900
Practice Address - Country:US
Practice Address - Phone:631-780-6126
Practice Address - Fax:631-256-4844
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY661228163W00000X
NY342007363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse