Provider Demographics
NPI:1477199792
Name:SMITH, ELIZABETH DENISE (RN)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:DENISE
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 1:16450 W VAN BUREN ST APT 1066
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-1604
Mailing Address - Country:US
Mailing Address - Phone:317-260-8074
Mailing Address - Fax:
Practice Address - Street 1:751 N 215TH AVE
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-6525
Practice Address - Country:US
Practice Address - Phone:623-238-3514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN156404163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZRN156404Medicaid