Provider Demographics
NPI:1740876689
Name:SMITH, DESIREE (AGNP-C)
Entity type:Individual
Prefix:MS
First Name:DESIREE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16214 ELLIPSE TER
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3242
Mailing Address - Country:US
Mailing Address - Phone:205-480-7458
Mailing Address - Fax:
Practice Address - Street 1:90 RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-4303
Practice Address - Country:US
Practice Address - Phone:410-987-2003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR222153363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR222153OtherBOARD OF NURSING