Provider Demographics
NPI:1124799655
Name:SMITH, AVERY (CRNA)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:AMALIE
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1101 W PRATT BLVD APT 2W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-4477
Mailing Address - Country:US
Mailing Address - Phone:312-953-0564
Mailing Address - Fax:
Practice Address - Street 1:1101 W PRATT BLVD APT 2W
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-4477
Practice Address - Country:US
Practice Address - Phone:312-953-0564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041400420163W00000X
WI25878830163W00000X
IL209027680367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse