Provider Demographics
NPI:1447973797
Name:SMITH, BRENNA ASHLEY
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:ASHLEY
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25986 BENTON WAY
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-6956
Mailing Address - Country:US
Mailing Address - Phone:660-988-7402
Mailing Address - Fax:
Practice Address - Street 1:450 E SIGLER AVE STE A
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:MO
Practice Address - Zip Code:63555-1726
Practice Address - Country:US
Practice Address - Phone:660-465-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018012663163WE0003X
MO2023003913363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency