Provider Demographics
NPI:1770928343
Name:SMITH, SHAFONNE MONIQUE (WHNP-BC)
Entity type:Individual
Prefix:
First Name:SHAFONNE
Middle Name:MONIQUE
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 1:401 HOLLY HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63111-2410
Mailing Address - Country:US
Mailing Address - Phone:314-353-5190
Mailing Address - Fax:314-353-7631
Practice Address - Street 1:401 HOLLY HILLS AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63111-2410
Practice Address - Country:US
Practice Address - Phone:314-353-5190
Practice Address - Fax:314-353-7631
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016009888363LA2200X, 363LG0600X
MO2024011653225700000X
IN28208566A363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health