Provider Demographics
NPI:1174533202
Name:SMITH-DANIELSON, MIMI SUE (ARNP)
Entity type:Individual
Prefix:MS
First Name:MIMI
Middle Name:SUE
Last Name:SMITH-DANIELSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26788 HIGHLAND RD NE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98346
Mailing Address - Country:US
Mailing Address - Phone:360-297-8876
Mailing Address - Fax:360-297-0777
Practice Address - Street 1:26788 HIGHLAND RD NE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346
Practice Address - Country:US
Practice Address - Phone:360-297-8876
Practice Address - Fax:360-297-0777
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00039969163W00000X
WAAP30001519363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2813SMOtherREGENCE
WA9633819Medicaid
WA9633819Medicaid