Provider Demographics
NPI:1962885202
Name:SMITH, SHELBY
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-1525
Mailing Address - Country:US
Mailing Address - Phone:301-367-4439
Mailing Address - Fax:
Practice Address - Street 1:111 MICHIGAN AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2916
Practice Address - Country:US
Practice Address - Phone:301-367-4439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY687196163W00000X
NY382605363LP0200X
DCRN1044497363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse