Basic Information
| Provider Information | |||||||||
| NPI: | 1740247352 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.N., F.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 MEEKER ST | ||||||||
| Address2: | |||||||||
| City: | DELTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814161920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708745777 | ||||||||
| FaxNumber: | 9708741631 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 MEEKER ST | ||||||||
| Address2: | |||||||||
| City: | DELTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814161920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708745777 | ||||||||
| FaxNumber: | 9708741631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 10/19/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 98432 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 07984321 | 05 | CO | MEDICAID |