Healthcare Provider Details

I. General information

NPI: 1487190260
Provider Name (Legal Business Name): KARISSA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11115 WEST HIGHWAY 24 UNIT 2C
DIVIDE CO
80814-0928
US

IV. Provider business mailing address

PO BOX 928
DIVIDE CO
80814-0928
US

V. Phone/Fax

Practice location:
  • Phone: 719-687-6416
  • Fax: 719-687-6501
Mailing address:
  • Phone: 719-687-6416
  • Fax: 719-687-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.1637676
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: