Provider Demographics
NPI:1801270749
Name:SMITH, JEREMY LEE (APRN, NP-C)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4619 KANAWHA AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1319
Mailing Address - Country:US
Mailing Address - Phone:304-400-4545
Mailing Address - Fax:
Practice Address - Street 1:4619 KANAWHA AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1319
Practice Address - Country:US
Practice Address - Phone:304-400-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN81644-NP-C363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily