Provider Demographics
NPI:1609883867
Name:SMITH, RUTH (FNP)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:309-672-4809
Mailing Address - Fax:
Practice Address - Street 1:1112 5TH ST
Practice Address - Street 2:
Practice Address - City:LACON
Practice Address - State:IL
Practice Address - Zip Code:61540-1353
Practice Address - Country:US
Practice Address - Phone:309-246-2676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000505363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7215059OtherBCBS PPO
ILIL01R4OtherJOHN DEERE
IL472305OtherHEALTHLINK
IL010681OtherHEALTH ALLIANCE
IL500016195OtherRAILROAD MEDICARE
IL500016195OtherRAILROAD MEDICARE
ILK00352Medicare ID - Type Unspecified