Provider Demographics
NPI:1366981177
Name:SMITH, PHILLIP (ARNP)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 PINTAIL BLVD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:FL
Mailing Address - Zip Code:32439-3514
Mailing Address - Country:US
Mailing Address - Phone:256-283-8793
Mailing Address - Fax:
Practice Address - Street 1:281 STATE HIGHWAY 20 E
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:FL
Practice Address - Zip Code:32439-3929
Practice Address - Country:US
Practice Address - Phone:850-835-1235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-14
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9422096363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner