Provider Demographics
NPI:1124672258
Name:SMITH, RACHEL ANNE
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4088 VANDERSTOW RD
Mailing Address - Street 2:
Mailing Address - City:MORAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:13118-3556
Mailing Address - Country:US
Mailing Address - Phone:315-604-2800
Mailing Address - Fax:
Practice Address - Street 1:1275 STATE ROUTE 5 LOT 316
Practice Address - Street 2:
Practice Address - City:ELBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:13060-9685
Practice Address - Country:US
Practice Address - Phone:315-406-1583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336194164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse