Provider Demographics
NPI:1689948424
Name:SMITH, DIANA (NP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 W CORONA AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1210
Mailing Address - Country:US
Mailing Address - Phone:719-553-7521
Mailing Address - Fax:719-229-4672
Practice Address - Street 1:635 W CORONA AVE STE 200
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-1210
Practice Address - Country:US
Practice Address - Phone:719-553-7521
Practice Address - Fax:719-229-4672
Is Sole Proprietor?:No
Enumeration Date:2012-02-24
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN81430163WC1500X
COAPN.0991239-NP364SP0808X
CO991239363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1G4858OtherMEDICARE
CO39278352Medicaid