MEDICARE: MS. CARRIE SUSAN SMITH NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	1050	MN
2	363L00000X	Nurse Practitioner	R160154-7	MN

General Provider Information

NPI Number	:	1437143955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CARRIE SUSAN SMITH NP

Provider Business Mailing Address
First Line	:	13176 MARIGOLD ST NW
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55448-1089
Country	:	US
Telephone Number	:	763-712-5695
Fax Number	:

Provider Business Practice Location Address
First Line	:	333 WASHINGTON AVE N
Second Line	:	SUITE 5000
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55401-1377
Country	:	US
Telephone Number	:	763-712-5974
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	11/09/2020

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