Provider Demographics
NPI:1992760631
Name:SMITH, ROBERT JOHN (LPN)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JOHN
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 JOEL DR
Mailing Address - Street 2:MANAGED CARE DIVISION
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5318
Mailing Address - Country:US
Mailing Address - Phone:270-798-8766
Mailing Address - Fax:630-570-5225
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:MANAGED CARE DIVISION
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-798-8766
Practice Address - Fax:630-570-5225
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPN0000049998164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNLPN0000049998OtherNURSING LICENSE