Basic Information
Provider Information
NPI: 1003298035
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SMITH
FirstName: NATACHA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2423 W SAND LAKE
Address2:  
City: ORLANDO
State: FL
PostalCode: 347464094
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 2423 W SAND LAKE
Address2:  
City: ORLANDO
State: FL
PostalCode: 328094094
CountryCode: US
TelephoneNumber: 4078476117
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/26/2015
LastUpdateDate: 09/02/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LP0808XARNP9402723FLY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsych/Mental Health

No ID Information.


Home