Healthcare Provider Details

I. General information

NPI: 1508250580
Provider Name (Legal Business Name): DIANE SMITH APRN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10648 S REMBRANDT LN
SANDY UT
84070-5224
US

IV. Provider business mailing address

1301 BERTHA HOWE AVE SUITE 1
MESQUITE NV
89027-7502
US

V. Phone/Fax

Practice location:
  • Phone: 435-313-3142
  • Fax: 801-705-0118
Mailing address:
  • Phone: 702-346-0800
  • Fax: 702-346-0801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN001916
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8775403-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: