Healthcare Provider Details

I. General information

NPI: 1093623662
Provider Name (Legal Business Name): SYDNEY NICOLE WALSH SMITH FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 KMBL
PROVO UT
84602-4704
US

IV. Provider business mailing address

500 KMBL
PROVO UT
84602-4704
US

V. Phone/Fax

Practice location:
  • Phone: 801-600-3582
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11775617-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: