Provider Demographics
NPI:1356854285
Name:SMITH, DESIREE I (RN)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:I
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 N HOUSTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-5627
Mailing Address - Country:US
Mailing Address - Phone:575-749-2065
Mailing Address - Fax:
Practice Address - Street 1:701 W 18TH ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-7237
Practice Address - Country:US
Practice Address - Phone:575-356-3675
Practice Address - Fax:575-359-3675
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR66027163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool