Provider Demographics
NPI:1962588657
Name:SMITH, CECELIA L (NP)
Entity type:Individual
Prefix:
First Name:CECELIA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CECELIA
Other - Middle Name:L
Other - Last Name:CASSIDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 746720
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6720
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:2240 E 53RD ST # B1
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3479
Practice Address - Country:US
Practice Address - Phone:317-933-7047
Practice Address - Fax:317-667-1574
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001194363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200351900Medicaid
IN200351900Medicaid
IN548980MMedicare PIN
INP45806Medicare UPIN
INM400056735Medicare PIN