Provider Demographics
NPI:1588275929
Name:DIANA SMITH PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER LLC
Entity type:Organization
Organization Name:DIANA SMITH PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:719-553-7521
Mailing Address - Street 1:635 W CORONA AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1210
Mailing Address - Country:US
Mailing Address - Phone:719-553-7521
Mailing Address - Fax:719-299-4672
Practice Address - Street 1:635 W CORONA AVE STE 200
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-1210
Practice Address - Country:US
Practice Address - Phone:719-553-7521
Practice Address - Fax:719-299-4672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-10
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1G4859OtherMEDICARE
CO9000189137Medicaid