Healthcare Provider Details

I. General information

NPI: 1669458428
Provider Name (Legal Business Name): SUSAN MARIE SMITH CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 CURVE CREST BLVD W
STILLWATER MN
55082-6040
US

IV. Provider business mailing address

1500 CURVE CREST BLVD W
STILLWATER MN
55082-6040
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-1234
  • Fax: 651-439-1547
Mailing address:
  • Phone: 651-439-1234
  • Fax: 651-439-1547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR0874443
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: