Healthcare Provider Details

I. General information

NPI: 1932871415
Provider Name (Legal Business Name): EMILY MARIE SMITH DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 10/01/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

581 W CHARLEY WAY
ERDA UT
84074-9413
US

IV. Provider business mailing address

581 W CHARLEY WAY
ERDA UT
84074-9413
US

V. Phone/Fax

Practice location:
  • Phone: 575-520-2164
  • Fax:
Mailing address:
  • Phone: 575-520-2164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11030575-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: