Provider Demographics
NPI:1225473994
Name:SMITH, CONCEPCION
Entity Type:Individual
Prefix:MS
First Name:CONCEPCION
Middle Name:
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 1:6520 ELM ST SE
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-5540
Mailing Address - Country:US
Mailing Address - Phone:360-943-9767
Mailing Address - Fax:
Practice Address - Street 1:6520 ELM ST SE
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-5540
Practice Address - Country:US
Practice Address - Phone:360-943-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA218000376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA572253OtherPROVIDER NUMBER