Provider Demographics
NPI:1124629035
Name:SMITH, CARLA SUE (CNS)
Entity type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:SUE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:MISS
Other - First Name:CARLA
Other - Middle Name:SUE
Other - Last Name:SHAFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 7005
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-7005
Mailing Address - Country:US
Mailing Address - Phone:217-223-8400
Mailing Address - Fax:217-214-5675
Practice Address - Street 1:1005 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2834
Practice Address - Country:US
Practice Address - Phone:217-223-8400
Practice Address - Fax:217-214-5675
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.000880364SX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology