Provider Demographics
NPI:1992786909
Name:SMITH, MARCY (CNP)
Entity type:Individual
Prefix:
First Name:MARCY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4504 WAYNESBORO RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-3823
Mailing Address - Country:US
Mailing Address - Phone:505-897-8642
Mailing Address - Fax:
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2745
Practice Address - Country:US
Practice Address - Phone:505-272-3189
Practice Address - Fax:505-272-2330
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR9390363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM300999OtherPTAN NUMBER
NM93369OtherMEDICAID NUMBER
NMR9390OtherNURSING LICENSE
S52778Medicare UPIN