Provider Demographics
NPI:1740334531
Name:SMITH, DEBORAH SUE (APRN, FNP)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:SUE
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 HOLLYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2216
Mailing Address - Country:US
Mailing Address - Phone:801-201-0585
Mailing Address - Fax:
Practice Address - Street 1:1250 E 3900 S
Practice Address - Street 2:SUITE 440
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1348
Practice Address - Country:US
Practice Address - Phone:801-261-2232
Practice Address - Fax:801-264-1138
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT264106-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP18398Medicare UPIN