Provider Demographics
NPI:1508452921
Name:SALLY SMITH NP, LLC
Entity Type:Organization
Organization Name:SALLY SMITH NP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:505-570-7858
Mailing Address - Street 1:96 LOS ALTOS DE CICUYE
Mailing Address - Street 2:
Mailing Address - City:PECOS
Mailing Address - State:NM
Mailing Address - Zip Code:87552-2555
Mailing Address - Country:US
Mailing Address - Phone:505-310-6974
Mailing Address - Fax:
Practice Address - Street 1:1640 OLD PECOS TRL STE E&F
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4776
Practice Address - Country:US
Practice Address - Phone:505-310-6974
Practice Address - Fax:855-795-1933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-19
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1861981193Medicaid