Healthcare Provider Details

I. General information

NPI: 1790077089
Provider Name (Legal Business Name): MISTY D SMITH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2011
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 MANASSAS CIR
BOSSIER CITY LA
71112-4842
US

IV. Provider business mailing address

620 MANASSAS CIR
BOSSIER CITY LA
71112-4842
US

V. Phone/Fax

Practice location:
  • Phone: 318-458-9088
  • Fax:
Mailing address:
  • Phone: 318-458-9088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number794816
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP06370
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: