Provider Demographics
NPI:1174140776
Name:SMITH, SAMANTHA ELIZABETH (FNP)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 MEDICAL ST
Practice Address - Street 2:
Practice Address - City:PILOT MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:27041-8656
Practice Address - Country:US
Practice Address - Phone:336-368-5011
Practice Address - Fax:336-368-1424
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5013251363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner