1639783053 NPI number — MRS. ERICKA RENEE SMITH DA 3160

Table of content: MRS. ERICKA RENEE SMITH DA 3160 (NPI 1639783053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639783053 NPI number — MRS. ERICKA RENEE SMITH DA 3160

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
ERICKA
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DA 3160
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DENNIS
Provider Other First Name:
ERICKA
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639783053
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
280 1ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLOMAN AFB
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88330-8273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-572-3742
Provider Business Mailing Address Fax Number:
575-572-7634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
280 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLOMAN AFB
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88330-8273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-572-3742
Provider Business Practice Location Address Fax Number:
575-572-7634
Provider Enumeration Date:
09/02/2020

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: 126800000X , with the licence number:  DA3160 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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