=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487190260
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KARISSA SMITH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2017
-----------------------------------------------------
Last Update Date | 01/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11115 WEST HIGHWAY 24 UNIT 2C
-----------------------------------------------------
City | DIVIDE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80814-0928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-687-6416
-----------------------------------------------------
Fax | 719-687-6501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 928
-----------------------------------------------------
City | DIVIDE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80814-0928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-687-6416
-----------------------------------------------------
Fax | 719-687-6501
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN.1637676
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------