Provider Demographics
NPI:1316643398
Name:SMITHERMAN, ETHAN TYLER (PMHNP)
Entity type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:TYLER
Last Name:SMITHERMAN
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 W VALLEY ST STE 108
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-1749
Mailing Address - Country:US
Mailing Address - Phone:901-491-0130
Mailing Address - Fax:
Practice Address - Street 1:324 W VALLEY ST STE 108
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-1749
Practice Address - Country:US
Practice Address - Phone:901-491-0130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905753363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health