Provider Demographics
NPI:1699353425
Name:SMITH, MELANIE ANNE
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:ANNE
Last Name:SMITH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4610 N ASHLAND AVE APT 1N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5678
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2890 W WALNUT ST STE 2
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-0335
Practice Address - Country:US
Practice Address - Phone:479-372-6201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023105363LF0000X
AR232243363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily