Provider Demographics
NPI:1487259396
Name:SMITH, CONNIE MARIE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:ATKINSON
Mailing Address - State:NE
Mailing Address - Zip Code:68713-0547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ATKINSON
Practice Address - State:NE
Practice Address - Zip Code:68713-4952
Practice Address - Country:US
Practice Address - Phone:402-925-2848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE18744164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse