Provider Demographics
NPI:1780163014
Name:SMITH, SARA BONITA
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:BONITA
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 US HIGHWAY 80 E APT 5305
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-5754
Mailing Address - Country:US
Mailing Address - Phone:469-540-2376
Mailing Address - Fax:
Practice Address - Street 1:909 US HIGHWAY 80 E APT 5305
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-5754
Practice Address - Country:US
Practice Address - Phone:469-540-2376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX227100164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse