Provider Demographics
NPI:1033252044
Name:SMITH, DIANE PATRICIA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:PATRICIA
Last Name:SMITH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-1716
Mailing Address - Country:US
Mailing Address - Phone:303-772-6244
Mailing Address - Fax:303-702-1623
Practice Address - Street 1:205 S MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1716
Practice Address - Country:US
Practice Address - Phone:303-772-6244
Practice Address - Fax:303-702-1623
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO179580363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO42101069Medicaid
CO808307Medicare PIN