Provider Demographics
NPI:1487877130
Name:SMITH, JONNELLE D (PA)
Entity type:Individual
Prefix:MS
First Name:JONNELLE
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:523 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:IL
Practice Address - Zip Code:62016-1256
Practice Address - Country:US
Practice Address - Phone:217-942-3326
Practice Address - Fax:217-942-9833
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IL085 002986207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL567730010Medicare PIN