Healthcare Provider Details

I. General information

NPI: 1790377075
Provider Name (Legal Business Name): BRIAN C SMITH CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 E TAMPA ST
SPRINGFIELD MO
65806-1131
US

IV. Provider business mailing address

440 E TAMPA ST
SPRINGFIELD MO
65806-1131
US

V. Phone/Fax

Practice location:
  • Phone: 417-851-1551
  • Fax: 417-865-3479
Mailing address:
  • Phone: 417-851-1551
  • Fax: 417-865-3479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2017004849
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: