Provider Demographics
NPI:1063599595
Name:SMITH, MARY ELIZABETH (ANP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:LIBBY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:515 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1513
Mailing Address - Country:US
Mailing Address - Phone:716-945-0361
Mailing Address - Fax:
Practice Address - Street 1:4039 ROUTE 219
Practice Address - Street 2:SUITE 101
Practice Address - City:SALAMANCA
Practice Address - State:NY
Practice Address - Zip Code:14779-9625
Practice Address - Country:US
Practice Address - Phone:716-945-0361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3020031363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0300F302003Medicaid
NY000560328002OtherBLUE CROSS
NY0300F302003Medicaid
NY000560328002OtherBLUE CROSS