Provider Demographics
NPI:1053413294
Name:SMITH LIGHTFOOT, MARTHA (NP)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:SMITH LIGHTFOOT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 MOUNT HOPE AVE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3917
Mailing Address - Country:US
Mailing Address - Phone:585-275-7854
Mailing Address - Fax:585-275-9953
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX 278984
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-7854
Practice Address - Fax:585-275-9953
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300857363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02753579Medicaid