Provider Demographics
NPI:1386615771
Name:SMITH, CAROLYN J (NP)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5330 E STOP 11 RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-6345
Mailing Address - Country:US
Mailing Address - Phone:317-893-1900
Mailing Address - Fax:
Practice Address - Street 1:5330 E STOP 11 RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6345
Practice Address - Country:US
Practice Address - Phone:317-893-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000531A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP18809Medicare UPIN
IN117700GGMedicare ID - Type Unspecified