Provider Demographics
NPI:1912431826
Name:SMITH, COURTNEY NICOLE (IDC)
Entity Type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS THEODORE ROOSEVELT CVN 71
Mailing Address - Street 2:UNIT 10025 MEDICAL
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96632
Mailing Address - Country:US
Mailing Address - Phone:757-779-7307
Mailing Address - Fax:
Practice Address - Street 1:USS THEODORE ROOSEVELT CVN 71
Practice Address - Street 2:UNIT 10025 MEDICAL
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96632
Practice Address - Country:US
Practice Address - Phone:757-779-7307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman