1396744116 NPI number — MRS. JILL M SMITH APRN

Table of content: MRS. JILL M SMITH APRN (NPI 1396744116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396744116 NPI number — MRS. JILL M SMITH APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
JILL
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396744116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7707 E CENTRAL AVE
Provider Second Line Business Mailing Address:
LITTLE CLINIC CENTRAL & ROCK
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67206-2100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-207-9640
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4013 N RIDGE RD
Provider Second Line Business Practice Location Address:
STE 210
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67205-8860
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-945-7309
Provider Business Practice Location Address Fax Number:
316-945-9131
Provider Enumeration Date:
07/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  45619 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200267830A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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