Provider Demographics
NPI:1639641566
Name:SMART, RICHELE LEANN (PA)
Entity type:Individual
Prefix:
First Name:RICHELE
Middle Name:LEANN
Last Name:SMART
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:RICHELE
Other - Middle Name:LEANN
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2218 N 93RD LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-4402
Mailing Address - Country:US
Mailing Address - Phone:623-692-6003
Mailing Address - Fax:
Practice Address - Street 1:9060 E VIA LINDA STE 250
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5425
Practice Address - Country:US
Practice Address - Phone:480-500-2285
Practice Address - Fax:919-882-9575
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7391363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant