Provider Demographics
NPI:1508552829
Name:SMITH, RACHAEL EVE (PNP-PC)
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:EVE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1620 S KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4547
Practice Address - Country:US
Practice Address - Phone:208-505-2950
Practice Address - Fax:208-505-2955
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-214478363LP0200X
ID2661878363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics