=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407847726
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEANNA MARIE BROOKS SMITH CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2005
-----------------------------------------------------
Last Update Date | 05/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 DOOLITTLE DRIVE
-----------------------------------------------------
City | ELLSWORTH AIR FORCE BASE
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-385-3111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 DOOLITTLE DRIVE ATTEN MEDICAL STAFF SERVICES
-----------------------------------------------------
City | ELLSWORTH AIR FORCE BASE
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-385-3111
-----------------------------------------------------
Fax | 605-385-3680
-----------------------------------------------------
=====================================================
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 | CP000344
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------