Healthcare Provider Details

I. General information

NPI: 1720678014
Provider Name (Legal Business Name): LAURA KAY SMITH DTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FORT ST
BOISE ID
83702-4501
US

IV. Provider business mailing address

2692 N KRISTY AVE
KUNA ID
83634-5258
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1000
  • Fax:
Mailing address:
  • Phone: 208-985-4050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: