Provider Demographics
NPI:1245739838
Name:SMITH, SARAH BEATRICE
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:BEATRICE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4387 S HEATHER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-6491
Mailing Address - Country:US
Mailing Address - Phone:760-985-8427
Mailing Address - Fax:
Practice Address - Street 1:1851 MESQUITE AVE STE 210
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5681
Practice Address - Country:US
Practice Address - Phone:928-854-7540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN166916163WC0200X
AZAP11077363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine