Provider Demographics
NPI:1912256744
Name:SMITH, SARA NICOLE (NP)
Entity type:Individual
Prefix:MS
First Name:SARA
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:NICOLE
Other - Last Name:COPLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2108 E THOMAS RD STE 130
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-0008
Mailing Address - Country:US
Mailing Address - Phone:602-933-3124
Mailing Address - Fax:
Practice Address - Street 1:19007 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7179
Practice Address - Country:US
Practice Address - Phone:602-933-0016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN001966363LP0200X, 363LP0222X
OH13818-NP363LP0222X
AZ309490363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0131245Medicaid