Healthcare Provider Details

I. General information

NPI: 1073066114
Provider Name (Legal Business Name): ANTOINETTE MARIE SMITH BA,AA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. ANTOINETTE MARIE SMITH

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 MOON ST NE
ALBUQUERQUE NM
87112-3935
US

IV. Provider business mailing address

1299 ZEPOL RD UNIT 80
SANTA FE NM
87507-3090
US

V. Phone/Fax

Practice location:
  • Phone: 505-271-3029
  • Fax:
Mailing address:
  • Phone: 505-920-6999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: