Provider Demographics
NPI:1407847726
Name:BROOKS SMITH, LEANNA MARIE (CNP)
Entity Type:Individual
Prefix:
First Name:LEANNA
Middle Name:MARIE
Last Name:BROOKS SMITH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:LEANNA
Other - Middle Name:
Other - Last Name:BROOKS SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNP
Mailing Address - Street 1:2900 DOOLITTLE DRIVE
Mailing Address - Street 2:ATTEN MEDICAL STAFF SERVICES
Mailing Address - City:ELLSWORTH AIR FORCE BASE
Mailing Address - State:SD
Mailing Address - Zip Code:57706
Mailing Address - Country:US
Mailing Address - Phone:605-385-3111
Mailing Address - Fax:605-385-3680
Practice Address - Street 1:2900 DOOLITTLE DRIVE
Practice Address - Street 2:
Practice Address - City:ELLSWORTH AIR FORCE BASE
Practice Address - State:SD
Practice Address - Zip Code:57760
Practice Address - Country:US
Practice Address - Phone:605-385-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000344363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDCP000344OtherLICENSE
102200Medicare PIN