Provider Demographics
NPI:1164706677
Name:SMITH, PATRICIA (RN)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19420 N 59TH AVE STE B233
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6886
Mailing Address - Country:US
Mailing Address - Phone:505-984-0356
Mailing Address - Fax:
Practice Address - Street 1:490B W ZIA RD STE 1
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7009
Practice Address - Country:US
Practice Address - Phone:505-995-8346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR34622174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR62054OtherLICENSE/ CERTIFICATION NUMBER