Provider Demographics
NPI:1710713201
Name:SMYTHE, RAEGEN
Entity type:Individual
Prefix:
First Name:RAEGEN
Middle Name:
Last Name:SMYTHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MEADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:CANASERAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14822-9743
Mailing Address - Country:US
Mailing Address - Phone:607-725-1805
Mailing Address - Fax:
Practice Address - Street 1:7309 SENECA RD N
Practice Address - Street 2:
Practice Address - City:HORNELL
Practice Address - State:NY
Practice Address - Zip Code:14843-9691
Practice Address - Country:US
Practice Address - Phone:607-282-5200
Practice Address - Fax:585-335-5061
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY326977-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY161039939Medicaid
NY161039939OtherALL OTHER INSURANCES