=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942832787
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NIKKO M SMITH REGISTERED NURSE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2020
-----------------------------------------------------
Last Update Date | 02/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 NORTH 7TH STREET
-----------------------------------------------------
City | SARATOGA
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-305-0693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 146
-----------------------------------------------------
City | SARATOGA
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82331-0146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-305-0693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 29096
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------