Provider Demographics
NPI:1285934604
Name:SMITH, MARYBETH (APN, FNP-C)
Entity type:Individual
Prefix:MRS
First Name:MARYBETH
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:APN, FNP-C
Other - Prefix:
Other - First Name:MARYBETH
Other - Middle Name:
Other - Last Name:BAUMBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10724 STATE ROUTE 212 NE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:OH
Mailing Address - Zip Code:44612-8740
Mailing Address - Country:US
Mailing Address - Phone:330-874-7165
Mailing Address - Fax:330-874-7166
Practice Address - Street 1:10724 STATE ROUTE 212 NE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:OH
Practice Address - Zip Code:44612-8740
Practice Address - Country:US
Practice Address - Phone:330-874-7165
Practice Address - Fax:330-874-7166
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11140363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0127945Medicaid
OHH355300Medicare PIN