Provider Demographics
NPI:1902585318
Name:SMOOTS, SUSAN LORAINE (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LORAINE
Last Name:SMOOTS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 S BROAD ST # B
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-1933
Mailing Address - Country:US
Mailing Address - Phone:919-928-8188
Mailing Address - Fax:
Practice Address - Street 1:1415 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7338
Practice Address - Country:US
Practice Address - Phone:910-662-9500
Practice Address - Fax:910-662-9501
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC5018414363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner