Provider Demographics
NPI:1861591067
Name:SMITH, CAROL LEE (MSN CRNP)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSN CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 VINEYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047
Mailing Address - Country:US
Mailing Address - Phone:601-291-9882
Mailing Address - Fax:
Practice Address - Street 1:1500 WOODROW WILSON
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5199
Practice Address - Country:US
Practice Address - Phone:800-949-1009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-021304363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily