Provider Demographics
NPI:1932712288
Name:SMITH, NICOLE CHRISTINA (APRN-CNM)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CHRISTINA
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN-CNM
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:CHRISTINA
Other - Last Name:MATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 748817
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8817
Mailing Address - Country:US
Mailing Address - Phone:813-286-0033
Mailing Address - Fax:813-282-1806
Practice Address - Street 1:300 HEALTH PARK BLVD STE 3002
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3703
Practice Address - Country:US
Practice Address - Phone:937-802-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11019008363LW0102X, 367A00000X, 363LW0102X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN236040352OtherMEDICARE PTAN
IN300045317Medicaid