=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265891261
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAELYNN JO SMITH FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2016
-----------------------------------------------------
Last Update Date | 02/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1404 POMERELLE AVE SUITE B
-----------------------------------------------------
City | BURLEY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83318-2012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-878-9432
-----------------------------------------------------
Fax | 208-878-4576
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1404 POMERELLE AVE SUITE B
-----------------------------------------------------
City | BURLEY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83318-2012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-878-9432
-----------------------------------------------------
Fax | 208-878-4576
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | NP-1705A
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------