Basic Information
| Provider Information | |||||||||
| NPI: | 1861935058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CORTNEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | CORTNEY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 37 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153014062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7242231067 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 37 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153014062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7242231067 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2016 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 86299 | WV | N | Nursing Service Providers | Registered Nurse | 363LF0000X | SP017388 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN86299-NP-C | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | SP022853 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 251008110 | 05 | PA | MEDICAID | 251008110 | 01 | CRNP | OTHER |