Provider Demographics
NPI:1871914168
Name:SMITH, MARIA R (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:801 POLE LINE RD W
Practice Address - Street 2:SUITE 3880
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5810
Practice Address - Country:US
Practice Address - Phone:208-814-8500
Practice Address - Fax:208-814-8960
Is Sole Proprietor?:No
Enumeration Date:2014-01-03
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1391A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1871914168Medicaid