Provider Demographics
NPI:1700214525
Name:SMITH, EBONY (WHNP-BC)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 OPELOUSAS ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-2641
Mailing Address - Country:US
Mailing Address - Phone:337-493-9983
Mailing Address - Fax:337-310-1161
Practice Address - Street 1:500 PATTERSON ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-1849
Practice Address - Country:US
Practice Address - Phone:337-439-9983
Practice Address - Fax:337-310-1161
Is Sole Proprietor?:No
Enumeration Date:2013-10-15
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07542363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2350706Medicaid
LA2350706Medicaid