Provider Demographics
NPI:1306524012
Name:SMITH, ANGELINE ELIZABETH (ARNP)
Entity type:Individual
Prefix:
First Name:ANGELINE
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 HENRY CT
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-9533
Mailing Address - Country:US
Mailing Address - Phone:615-973-7793
Mailing Address - Fax:
Practice Address - Street 1:915 NE VALLEY RD
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-3845
Practice Address - Country:US
Practice Address - Phone:509-332-3548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-11
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID63793363L00000X
WAAP61430133363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner