Healthcare Provider Details

I. General information

NPI: 1023118890
Provider Name (Legal Business Name): SYLVIA K SMART RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 ABLONE LOOP
MESCALERO NM
88340-0210
US

IV. Provider business mailing address

PO BOX 143
GLENCOE NM
88324-0143
US

V. Phone/Fax

Practice location:
  • Phone: 505-464-3803
  • Fax:
Mailing address:
  • Phone: 505-464-3803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR22641
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: