Provider Demographics
NPI:1043239791
Name:SMITH, WENDY J (NP)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:J
Last Name:SMITH
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 1:8890 N UNION BLVD
Mailing Address - Street 2:STE 160
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7799
Mailing Address - Country:US
Mailing Address - Phone:719-365-9950
Mailing Address - Fax:719-365-9969
Practice Address - Street 1:525 N FOOTE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-4501
Practice Address - Country:US
Practice Address - Phone:719-365-6568
Practice Address - Fax:719-365-6317
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10187363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3349969Medicaid
CO89327853Medicaid
MS09455205Medicaid
TN4103232OtherBCBS TN
CO89327853Medicaid
MSP00188651Medicare PIN
MS500001706Medicare PIN
TN3349969Medicaid
TN4103232OtherBCBS TN
COCOAAA0300Medicare PIN