Provider Demographics
NPI:1124306097
Name:SMITH, VENETIA A (FNP)
Entity type:Individual
Prefix:MS
First Name:VENETIA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:VENETIA
Other - Middle Name:GAIL
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:6685 POPLAR AVE STE 120
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3742
Practice Address - Country:US
Practice Address - Phone:901-685-8245
Practice Address - Fax:901-685-8248
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN147887163W00000X
TN16104363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I500398OtherMEDICARE