Provider Demographics
NPI:1700367984
Name:SMITH, NICHOLE LEANN (CPT)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:LEANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-4255
Mailing Address - Country:US
Mailing Address - Phone:208-467-1560
Mailing Address - Fax:
Practice Address - Street 1:700 12TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4255
Practice Address - Country:US
Practice Address - Phone:208-467-1560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCT42115183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician