Provider Demographics
NPI:1811537244
Name:SMITH, CASSANDRA L (NP)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 N ARSENAL AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-3808
Mailing Address - Country:US
Mailing Address - Phone:317-423-0130
Mailing Address - Fax:317-423-0608
Practice Address - Street 1:26 N ARSENAL AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-3808
Practice Address - Country:US
Practice Address - Phone:317-423-0130
Practice Address - Fax:317-423-0608
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010144A363LF0000X
IN28227651A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1102422594OtherANTHEM PTAN
IN300062697Medicaid