Healthcare Provider Details

I. General information

NPI: 1720736804
Provider Name (Legal Business Name): EMILY JEAN SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2022
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 FOOTHILLS RD
LAS CRUCES NM
88011-3626
US

IV. Provider business mailing address

3530 FOOTHILLS RD
LAS CRUCES NM
88011-3626
US

V. Phone/Fax

Practice location:
  • Phone: 575-532-6054
  • Fax: 575-532-0215
Mailing address:
  • Phone: 575-649-0899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF03220063
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: