Healthcare Provider Details

I. General information

NPI: 1407847726
Provider Name (Legal Business Name): LEANNA MARIE BROOKS SMITH CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEANNA BROOKS SMITH CNP

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 05/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 DOOLITTLE DRIVE
ELLSWORTH AIR FORCE BASE SD
57760
US

IV. Provider business mailing address

2900 DOOLITTLE DRIVE ATTEN MEDICAL STAFF SERVICES
ELLSWORTH AIR FORCE BASE SD
57706
US

V. Phone/Fax

Practice location:
  • Phone: 605-385-3111
  • Fax:
Mailing address:
  • Phone: 605-385-3111
  • Fax: 605-385-3680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP000344
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: