Healthcare Provider Details

I. General information

NPI: 1912256744
Provider Name (Legal Business Name): SARA NICOLE SMITH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SARA NICOLE COPLEY

II. Dates (important events)

Enumeration Date: 09/07/2012
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19007 N 67TH AVE
GLENDALE AZ
85308-7179
US

IV. Provider business mailing address

2108 E THOMAS RD STE 130
PHOENIX AZ
85016-0008
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-0016
  • Fax:
Mailing address:
  • Phone: 602-933-3124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN001966
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number13818-NP
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberAPRN001966
License Number StateNV
# 4
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number309490
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: