MEDICARE: SARAH BEATRICE SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC0200X	Critical Care Medicine Registered Nurse	RN166916	AZ
2	363LA2100X	Acute Care Nurse Practitioner	AP11077	AZ

General Provider Information

NPI Number	:	1245739838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH BEATRICE SMITH

Provider Business Mailing Address
First Line	:	4387 S HEATHER AVE
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-6491
Country	:	US
Telephone Number	:	760-985-8427
Fax Number	:

Provider Business Practice Location Address
First Line	:	1851 MESQUITE AVE STE 210
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5681
Country	:	US
Telephone Number	:	928-854-7540
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2018
Last Update Date	:	03/20/2018

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