Provider Demographics
NPI:1427354919
Name:SMITH, ADRIENNE L (APRN)
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 S WOODS DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3262
Mailing Address - Country:US
Mailing Address - Phone:321-636-3066
Mailing Address - Fax:321-636-2545
Practice Address - Street 1:699 W COCOA BEACH CSWY STE 401
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931
Practice Address - Country:US
Practice Address - Phone:321-784-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9220199363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP9220199OtherLICENSE NO.
FL009579300Medicaid