1417489501 NPI number — MS. BREANNE NICOLE SMITH CP60896258

Table of content: MS. BREANNE NICOLE SMITH CP60896258 (NPI 1417489501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417489501 NPI number — MS. BREANNE NICOLE SMITH CP60896258

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
BREANNE
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CP60896258
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417489501
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
927 N 4TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98902-1409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-895-1584
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PO BOX 217
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SELAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98942-0217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-457-0990
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/29/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  CP60896258 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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