Healthcare Provider Details

I. General information

NPI: 1164271763
Provider Name (Legal Business Name): MARLEY NICOLE SMITH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5777 E MAYO BLVD
PHOENIX AZ
85054-4502
US

IV. Provider business mailing address

PO BOX 860912
MINNEAPOLIS MN
55486-0912
US

V. Phone/Fax

Practice location:
  • Phone: 480-342-2000
  • Fax:
Mailing address:
  • Phone: 480-301-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11219
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: