Provider Demographics
NPI:1245428994
Name:SMITH, MONICA (NP)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17610 N 17TH LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-2524
Mailing Address - Country:US
Mailing Address - Phone:480-255-6393
Mailing Address - Fax:
Practice Address - Street 1:17610 N 17TH LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023
Practice Address - Country:US
Practice Address - Phone:480-255-6393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2759363LA2200X
AZAP 2759163WP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WP0000XNursing Service ProvidersRegistered NursePain Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ422237Medicaid