Provider Demographics
NPI:1588876254
Name:SMITH, MARY BONNIE (CPNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BONNIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3643 W FRONT ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7759
Mailing Address - Country:US
Mailing Address - Phone:231-935-0614
Mailing Address - Fax:231-935-0832
Practice Address - Street 1:3643 W FRONT ST
Practice Address - Street 2:SUITE C
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7759
Practice Address - Country:US
Practice Address - Phone:231-935-0614
Practice Address - Fax:231-935-0832
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704077230363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704077230OtherREGISTERED NURSE LICENSE