Provider Demographics
NPI:1306205471
Name:SMITH, MONTY RAY (RN)
Entity Type:Individual
Prefix:
First Name:MONTY
Middle Name:RAY
Last Name:SMITH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3911
Mailing Address - Country:US
Mailing Address - Phone:541-206-4265
Mailing Address - Fax:
Practice Address - Street 1:1419 OLIVE ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3911
Practice Address - Country:US
Practice Address - Phone:541-206-4265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200640518RN163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health