Provider Demographics
NPI:1053108837
Name:SMITH, DEZARAE L (CRNP)
Entity type:Individual
Prefix:
First Name:DEZARAE
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-3301
Mailing Address - Country:US
Mailing Address - Phone:914-942-2411
Mailing Address - Fax:
Practice Address - Street 1:1321 11TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-3301
Practice Address - Country:US
Practice Address - Phone:914-942-2411
Practice Address - Fax:814-943-6291
Is Sole Proprietor?:No
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP032761363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner