Basic Information
| Provider Information | |||||||||
| NPI: | 1821264565 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10140 CENTURION PKWY N | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322560532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046974100 | ||||||||
| FaxNumber: | 9046975102 | ||||||||
| Practice Location | |||||||||
| Address1: | 8331 N DAVIS HWY | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325146094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505054700 | ||||||||
| FaxNumber: | 8505054711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2008 | ||||||||
| LastUpdateDate: | 04/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN9473715 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | 130810 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 2080P0206X | APRN9473715 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 023348800 | 05 | FL | MEDICAID |