Provider Demographics
NPI:1306460852
Name:SMITH, SUSAN CHRISTINE (RN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CHRISTINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:CHRISTINE
Other - Last Name:MASON SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:607 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-1345
Mailing Address - Country:US
Mailing Address - Phone:208-983-8590
Mailing Address - Fax:
Practice Address - Street 1:607 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-1345
Practice Address - Country:US
Practice Address - Phone:208-983-9590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID34969163WM0705X
ID66063363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical