Provider Demographics
NPI:1720736804
Name:SMITH, EMILY JEAN
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:JEAN
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 1:3530 FOOTHILLS RD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-3626
Mailing Address - Country:US
Mailing Address - Phone:575-649-0899
Mailing Address - Fax:
Practice Address - Street 1:3530 FOOTHILLS RD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-3626
Practice Address - Country:US
Practice Address - Phone:575-532-6054
Practice Address - Fax:575-532-0215
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMF03220063363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1720736804OtherNPI