Provider Demographics
NPI:1558832956
Name:SMITH, SHANIECE (NP)
Entity type:Individual
Prefix:
First Name:SHANIECE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
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 749495
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9495
Mailing Address - Country:US
Mailing Address - Phone:855-963-2100
Mailing Address - Fax:239-236-2775
Practice Address - Street 1:8301 HARCOURT RD STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2082
Practice Address - Country:US
Practice Address - Phone:317-415-6600
Practice Address - Fax:317-415-6649
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INF09181038363LF0000X
IN71009045A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily