Provider Demographics
NPI:1720719578
Name:SMITH, RAEANN SUE (NP)
Entity Type:Individual
Prefix:
First Name:RAEANN
Middle Name:SUE
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 1:2919 VALMONT RD STE 204
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1350
Mailing Address - Country:US
Mailing Address - Phone:303-938-1110
Mailing Address - Fax:
Practice Address - Street 1:2919 VALMONT RD STE 204
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1350
Practice Address - Country:US
Practice Address - Phone:303-938-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0997636-NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
COAPN.0997636-NPOtherCOLORADO DEPARTMENT OF REGULATORY AGENCIES