Provider Demographics
NPI:1134588353
Name:SMITH, JOSHUA DALE (FNP)
Entity type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:DALE
Last Name:SMITH
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W RAVINE RD
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3868
Mailing Address - Country:US
Mailing Address - Phone:423-245-3161
Mailing Address - Fax:423-857-8129
Practice Address - Street 1:430 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3868
Practice Address - Country:US
Practice Address - Phone:423-245-3161
Practice Address - Fax:423-857-8129
Is Sole Proprietor?:No
Enumeration Date:2016-02-16
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20838363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner