Provider Demographics
NPI:1437901790
Name:SMITH, SHANA RAE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:RAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 W GLENDALE AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-7673
Mailing Address - Country:US
Mailing Address - Phone:563-505-7686
Mailing Address - Fax:
Practice Address - Street 1:2401 W GLENDALE AVE STE 203
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-7673
Practice Address - Country:US
Practice Address - Phone:602-772-5770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ221317363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily