Provider Demographics
NPI:1922473578
Name:SMITH, ELIZABETH MARY TIMM (FNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARY TIMM
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 1:8600 SHERIDAN RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-6506
Mailing Address - Country:US
Mailing Address - Phone:262-605-6767
Mailing Address - Fax:
Practice Address - Street 1:8600 SHERIDAN RD
Practice Address - Street 2:SUITE 600
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-6506
Practice Address - Country:US
Practice Address - Phone:262-605-6767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6738-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily