Provider Demographics
NPI:1821059189
Name:SMITH, CYNTHIA LEE (FNP-C)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 W STOTTLER DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-2663
Mailing Address - Country:US
Mailing Address - Phone:480-963-9417
Mailing Address - Fax:
Practice Address - Street 1:515 N MESA DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-5914
Practice Address - Country:US
Practice Address - Phone:480-844-6285
Practice Address - Fax:480-844-4154
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN055481363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ773540Medicaid
AZ77407Medicare PIN
AZ101309Medicare UPIN