Provider Demographics
NPI:1386779247
Name:SMITH, SUSAN MARIE (ARNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:6142 COLLINS RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-5806
Practice Address - Country:US
Practice Address - Phone:904-778-3200
Practice Address - Fax:904-778-9835
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2865252363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01321223OtherRAILROAD MEDICARE
FLE4329XMedicare PIN