Provider Demographics
NPI:1831858687
Name:SMITH, MELISSA (LPN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 63
Mailing Address - Street 2:
Mailing Address - City:CIMARRON
Mailing Address - State:NM
Mailing Address - Zip Code:87714-0063
Mailing Address - Country:US
Mailing Address - Phone:575-447-5090
Mailing Address - Fax:
Practice Address - Street 1:165 N COLLISON AVE
Practice Address - Street 2:
Practice Address - City:CIMARRON
Practice Address - State:NM
Practice Address - Zip Code:87714-8505
Practice Address - Country:US
Practice Address - Phone:575-376-2445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NML17496164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse