Healthcare Provider Details

I. General information

NPI: 1861981193
Provider Name (Legal Business Name): SALLY ANNE SMITH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 05/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51A CALLE GURULE
SANTA FE NM
87505-1413
US

IV. Provider business mailing address

200 COLINAS
SEDONA AZ
86351-9244
US

V. Phone/Fax

Practice location:
  • Phone: 509-833-4858
  • Fax:
Mailing address:
  • Phone: 509-833-4858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-03515
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: