Provider Demographics
NPI:1114433885
Name:SMITH, PRINCESS MANNY
Entity Type:Individual
Prefix:
First Name:PRINCESS
Middle Name:MANNY
Last Name:SMITH
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 1:9564 MONROE ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-2539
Mailing Address - Country:US
Mailing Address - Phone:763-732-9142
Mailing Address - Fax:
Practice Address - Street 1:9564 MONROE ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-2539
Practice Address - Country:US
Practice Address - Phone:763-732-9142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2221900163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse