Provider Demographics
NPI:1255115309
Name:SMITH, STEFFANIE SUE
Entity type:Individual
Prefix:
First Name:STEFFANIE
Middle Name:SUE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2848 2ND ST S STE 135
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-3705
Mailing Address - Country:US
Mailing Address - Phone:763-428-2288
Mailing Address - Fax:763-428-2132
Practice Address - Street 1:2848 2ND ST S STE 135
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3705
Practice Address - Country:US
Practice Address - Phone:763-428-2288
Practice Address - Fax:763-428-2132
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10506363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health