Provider Demographics
NPI:1477512606
Name:SMITH, COURTNEY M (APRN)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 4TH ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1421
Mailing Address - Country:US
Mailing Address - Phone:651-292-2043
Mailing Address - Fax:651-292-2204
Practice Address - Street 1:4242 FARNAM ST
Practice Address - Street 2:#490
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2806
Practice Address - Country:US
Practice Address - Phone:402-504-3880
Practice Address - Fax:402-504-3859
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110716363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025290600Medicaid
Q50856Medicare UPIN
NE279308Medicare PIN