Basic Information
Provider Information | |||||||||
NPI: | 1417360637 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | JUSTINE | ||||||||
MiddleName: | MAEDEKER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MAEDEKER | ||||||||
OtherFirstName: | JUSTINE | ||||||||
OtherMiddleName: | APRIL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1328 | ||||||||
Address2: |   | ||||||||
City: | DURANGO | ||||||||
State: | CO | ||||||||
PostalCode: | 813021328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9703352238 | ||||||||
FaxNumber: | 9703352438 | ||||||||
Practice Location | |||||||||
Address1: | 691 E EMPIRE ST | ||||||||
Address2: |   | ||||||||
City: | CORTEZ | ||||||||
State: | CO | ||||||||
PostalCode: | 813212802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9705657946 | ||||||||
FaxNumber: | 7056579469 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/05/2014 | ||||||||
LastUpdateDate: | 02/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209011558 | IL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363L00000X | 2014014787 | MO | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363L00000X | 0993274 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.