Provider Demographics
NPI:1578681896
Name:SMITH, ELIZABETH KAY (NP)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:KAY
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:KAY
Other - Last Name:FORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:9495 SW LOCUST ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6683
Mailing Address - Country:US
Mailing Address - Phone:503-636-9011
Mailing Address - Fax:503-636-3952
Practice Address - Street 1:9495 SW LOCUST ST
Practice Address - Street 2:SUITE A
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-6683
Practice Address - Country:US
Practice Address - Phone:503-636-9011
Practice Address - Fax:503-636-3952
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAPNP200550056363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43930700Medicaid
WI012N73601Medicare ID - Type Unspecified
P26851Medicare UPIN