Provider Demographics
NPI:1881129146
Name:SMITH, SARA JEAN (NP-BC)
Entity type:Individual
Prefix:MRS
First Name:SARA
Middle Name:JEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:JEAN
Other - Last Name:RENGERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-5015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID55535363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology