Provider Demographics
NPI:1982707980
Name:SMITH, VICKI LEE (CNM)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 HOSPITAL PLZ
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452-8595
Mailing Address - Country:US
Mailing Address - Phone:304-269-3108
Mailing Address - Fax:304-517-1570
Practice Address - Street 1:66 HOSPITAL PLZ
Practice Address - Street 2:SUITE 104
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-8595
Practice Address - Country:US
Practice Address - Phone:304-269-3108
Practice Address - Fax:304-517-1570
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV132367A00000X
AK1080363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP0049Medicaid
WV7105230000Medicaid
SMNM75821Medicare ID - Type Unspecified
P96096Medicare UPIN
AKNP0049Medicaid
AK162363Medicare PIN