Healthcare Provider Details

I. General information

NPI: 1508452921
Provider Name (Legal Business Name): SALLY SMITH NP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2020
Last Update Date: 12/19/2020
Certification Date: 12/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 OLD PECOS TRL STE E&F
SANTA FE NM
87505-4776
US

IV. Provider business mailing address

96 LOS ALTOS DE CICUYE
PECOS NM
87552-2555
US

V. Phone/Fax

Practice location:
  • Phone: 505-310-6974
  • Fax: 855-795-1933
Mailing address:
  • Phone: 505-310-6974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. SALLY ANNE SMITH
Title or Position: NURSE PRACTITIONER
Credential: FNP
Phone: 505-570-7858