Provider Demographics
NPI:1710218151
Name:SMITH, SHEILA KATHLEEN (NP)
Entity Type:Individual
Prefix:DR
First Name:SHEILA
Middle Name:KATHLEEN
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 1:814 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415
Mailing Address - Country:US
Mailing Address - Phone:612-888-9792
Mailing Address - Fax:612-888-9762
Practice Address - Street 1:814 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415
Practice Address - Country:US
Practice Address - Phone:612-888-9792
Practice Address - Fax:612-888-9762
Is Sole Proprietor?:No
Enumeration Date:2010-01-25
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8039444363LA2200X
WI80289 -030363LA2200X
MN5091363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ000029Medicaid