Provider Demographics
NPI:1356541890
Name:SMITH, MARY LYNN (RN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 W GREENHEAD ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2879
Mailing Address - Country:US
Mailing Address - Phone:208-884-1124
Mailing Address - Fax:
Practice Address - Street 1:990 W GREENHEAD ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2879
Practice Address - Country:US
Practice Address - Phone:208-884-1124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-22405163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse