Provider Demographics
NPI:1386710598
Name:SMITH, REGINA P (FNP)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:P
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 NC HIGHWAY 109 S
Mailing Address - Street 2:
Mailing Address - City:MOUNT GILEAD
Mailing Address - State:NC
Mailing Address - Zip Code:27306-8941
Mailing Address - Country:US
Mailing Address - Phone:910-572-1979
Mailing Address - Fax:970-572-1961
Practice Address - Street 1:129 NC HIGHWAY 109 S
Practice Address - Street 2:
Practice Address - City:MOUNT GILEAD
Practice Address - State:NC
Practice Address - Zip Code:27306-8941
Practice Address - Country:US
Practice Address - Phone:910-572-1979
Practice Address - Fax:970-572-1961
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0050-02425363L00000X
NC5002425363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003896Medicaid