Provider Demographics
NPI:1114447406
Name:SMITH, BRANDI JO (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:JO
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2860 CHANNING WAY STE 115
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7532
Mailing Address - Country:US
Mailing Address - Phone:208-529-7283
Mailing Address - Fax:
Practice Address - Street 1:2860 CHANNING WAY
Practice Address - Street 2:SUITE 115
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-529-7283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID56069363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily