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1467786319 NPI number — CHARISSA BETHE'L SMITH ATC

NPI Number: 1467786319
Health Care Provider/Practitioner: CHARISSA BETHE'L SMITH ATC

Information about “1467786319” NPI (CHARISSA BETHE'L SMITH ATC) exists in 1467786319 in HTML format HTML  |  1467786319 in plain Text format TXT  |  1467786319 in PDF (Portable Document Format) PDF  |  1467786319 in an XML format XML  formats.

NPI Number : 1467786319 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1467786319",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "SMITH",
    "FirstName": "CHARISSA",
    "MiddleName": "BETHE'L",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "ATC",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "98 POPLAR ST",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "BLACKFOOT",
    "MailingAddressStateName": "ID",
    "MailingAddressPostalCode": "83221-1758",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "208-785-3841",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "1767 BLUE SKY DR",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "IDAHO FALLS",
    "PracticeLocationAddressStateName": "ID",
    "PracticeLocationAddressPostalCode": "83402-4802",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "208-525-7770",
    "PracticeLocationAddressFaxNumber": "208-525-7778",
    "EnumerationDate": "09/24/2009",
    "LastUpdateDate": "10/02/2018",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "2255A2300X",
          "TaxonomyName": "Athletic Trainer",
          "LicenseNumber": "AT-386",
          "LicenseNumberStateCode": "ID",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "2255A2300X",
          "TaxonomyName": "Athletic Trainer",
          "LicenseNumber": "0506221",
          "LicenseNumberStateCode": "NV",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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