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General NPI Number Information
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NPI Number | 1467786319
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Entity Type | Individual
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Provider Name | CHARISSA BETHE'L SMITH ATC
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Gender | Female
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Dates
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Enumeration Date | 09/24/2009
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Last Update Date | 10/02/2018
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Provider Practice Location Address
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Address Line | 1767 BLUE SKY DR
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City | IDAHO FALLS
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State | ID
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Zip | 83402-4802
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Country | US
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Telephone | 208-525-7770
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Fax | 208-525-7778
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Provider Business Mailing Address
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Address Line | 98 POPLAR ST
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City | BLACKFOOT
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State | ID
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Zip | 83221-1758
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Country | US
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Telephone | 208-785-3841
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT-386
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 0506221
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License Number State | NV
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