Provider Demographics
NPI:1770546632
Name:SMITH, ELIZABETH ANNE (NP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANNE
Other - Last Name:JUDKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2249 WEALTHY ST SE
Mailing Address - Street 2:STE 202
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3052
Mailing Address - Country:US
Mailing Address - Phone:248-952-1601
Mailing Address - Fax:248-952-1614
Practice Address - Street 1:2249 WEALTHY ST SE
Practice Address - Street 2:STE 202
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-3052
Practice Address - Country:US
Practice Address - Phone:248-952-1601
Practice Address - Fax:248-952-1614
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704228049363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P37699Medicare UPIN