Provider Demographics
NPI:1801363494
Name:SMITH, MARYANN MARIE
Entity type:Individual
Prefix:
First Name:MARYANN
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6227 FRANKFORT HWY
Mailing Address - Street 2:
Mailing Address - City:BENZONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49616-8632
Mailing Address - Country:US
Mailing Address - Phone:312-882-9661
Mailing Address - Fax:
Practice Address - Street 1:8225 LAKE ST
Practice Address - Street 2:
Practice Address - City:BEAR LAKE
Practice Address - State:MI
Practice Address - Zip Code:49614
Practice Address - Country:US
Practice Address - Phone:231-864-3314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant