Provider Demographics
NPI:1336329820
Name:SMITH, ELIZABETH ELLEN (APN, CNNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ELLEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:APN, CNNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:12750 ST FRANCIS DR
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-0264
Practice Address - Country:US
Practice Address - Phone:219-757-6004
Practice Address - Fax:219-681-6871
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004643A363LN0000X, 363LN0005X
IL209.006805363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28142802AOtherSTATE OF INDIANA
IN71004643BOtherSTATE OF IN
IN71004643AOtherSTATE OF INDIANA