Basic Information
| Provider Information | |||||||||
| NPI: | 1760968291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | OWEN | ||||||||
| MiddleName: | WOODFIELD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 620 N CAROLINE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212051895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103969410 | ||||||||
| FaxNumber: | 4103969437 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 N CAROLINE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212051839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103969410 | ||||||||
| FaxNumber: | 4103969437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2018 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R213409 | MD | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | R213409 | 01 | MD | REGISTERED NURSE - MARYLAND BOARD OF NURSING | OTHER |