Provider Demographics
NPI:1679901151
Name:SMITH, CHELSEA NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:CHELSEA
Other - Middle Name:NICOLE
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4216 CARROLLWOOD VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-8647
Mailing Address - Country:US
Mailing Address - Phone:727-504-8350
Mailing Address - Fax:
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-22
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107454363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014240400Medicaid
FLIB310YMedicare PIN
FL014240400Medicaid