Provider Demographics
NPI:1548353469
Name:SMITH, COREEN S (CNP, MS)
Entity type:Individual
Prefix:
First Name:COREEN
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNP, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 WHITE BEAR AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-5110
Mailing Address - Country:US
Mailing Address - Phone:651-600-3035
Mailing Address - Fax:651-348-8783
Practice Address - Street 1:2603 WHITE BEAR AVE N
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-5110
Practice Address - Country:US
Practice Address - Phone:651-600-3035
Practice Address - Fax:651-348-8783
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 1337363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209847/GROUPMedicare PIN