Healthcare Provider Details

I. General information

NPI: 1104062017
Provider Name (Legal Business Name): VICTORIA RAE SMITH LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2008
Last Update Date: 12/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 MASSACHUSETTS ST
LAWRENCE KS
66046-4827
US

IV. Provider business mailing address

2415 MASSACHUSETTS ST
LAWRENCE KS
66046-4827
US

V. Phone/Fax

Practice location:
  • Phone: 785-843-3750
  • Fax: 785-832-4887
Mailing address:
  • Phone: 785-843-3750
  • Fax: 785-832-4887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number23-17860-112
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: