Provider Demographics
NPI:1053177444
Name:SMITH, MARY ALICE (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 EDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SARANAC LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12983-1537
Mailing Address - Country:US
Mailing Address - Phone:518-354-4126
Mailing Address - Fax:
Practice Address - Street 1:70 EDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-1537
Practice Address - Country:US
Practice Address - Phone:518-354-4126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY453383-01163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health