Provider Demographics
NPI:1538478698
Name:SMITH, CARRISSA M (FSD)
Entity type:Individual
Prefix:MRS
First Name:CARRISSA
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:FSD
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 369
Mailing Address - Street 2:
Mailing Address - City:FREWSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14738-0369
Mailing Address - Country:US
Mailing Address - Phone:716-338-8391
Mailing Address - Fax:
Practice Address - Street 1:8 WATER ST
Practice Address - Street 2:
Practice Address - City:FREWSBURG
Practice Address - State:NY
Practice Address - Zip Code:14738-9703
Practice Address - Country:US
Practice Address - Phone:716-338-8391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-06
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY374J00000X
175M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175M00000XOther Service ProvidersMidwife, Lay
Yes374J00000XNursing Service Related ProvidersDoula