Healthcare Provider Details

I. General information

NPI: 1073591285
Provider Name (Legal Business Name): DIANE RUTH SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 BROOKLEY AVE.
BOLLING AFB DC
20332-0001
US

IV. Provider business mailing address

1016 S WAYNE ST #612
ARLINGTON VA
22204-4433
US

V. Phone/Fax

Practice location:
  • Phone: 202-404-3603
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0001040494
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: