Provider Demographics
NPI:1053024026
Name:BOUANANE-SMITH, MARIAM SOPHIA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:SOPHIA
Last Name:BOUANANE-SMITH
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3500 VIRGINIA BEACH BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-4445
Mailing Address - Country:US
Mailing Address - Phone:757-720-1040
Mailing Address - Fax:757-720-1041
Practice Address - Street 1:5511 PRINCESS ANNE RD STE 200
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3321
Practice Address - Country:US
Practice Address - Phone:757-704-4747
Practice Address - Fax:757-250-9863
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024187257363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health