Healthcare Provider Details

I. General information

NPI: 1144622168
Provider Name (Legal Business Name): ELIZABETH LOUISE SMITH APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 08/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 E ASPEN AVE
FRUITA CO
81521-2543
US

IV. Provider business mailing address

121 E ASPEN AVE
FRUITA CO
81521-2543
US

V. Phone/Fax

Practice location:
  • Phone: 970-201-6772
  • Fax:
Mailing address:
  • Phone: 970-201-6772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704273496
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1626779
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number991297
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: