Provider Demographics
NPI:1962748947
Name:SMITH, JEFFREY ALLEN (ARNP)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALLEN
Last Name:SMITH
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 KUHL AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2008
Mailing Address - Country:US
Mailing Address - Phone:321-843-5500
Mailing Address - Fax:321-843-5550
Practice Address - Street 1:1414 KUHL AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2008
Practice Address - Country:US
Practice Address - Phone:321-843-5500
Practice Address - Fax:321-843-5550
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-20
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9244877363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGW800ZMedicare PIN