Provider Demographics
NPI:1528016730
Name:SMITH, DEBRA S (CRNP)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2129 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-2123
Mailing Address - Country:US
Mailing Address - Phone:417-782-3308
Mailing Address - Fax:
Practice Address - Street 1:2817 MC CLELLAND BLVD
Practice Address - Street 2:STE 350
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1629
Practice Address - Country:US
Practice Address - Phone:417-782-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO142703363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA098015Medicare ID - Type Unspecified
Q62730Medicare UPIN