Provider Demographics
NPI:1063058576
Name:SMITH, EILEEN MARY (RN BSN)
Entity type:Individual
Prefix:MRS
First Name:EILEEN
Middle Name:MARY
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3003
Mailing Address - Country:US
Mailing Address - Phone:631-901-2138
Mailing Address - Fax:
Practice Address - Street 1:103 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3003
Practice Address - Country:US
Practice Address - Phone:631-687-4188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY551537163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator