Provider Demographics
NPI:1144767104
Name:LAURA SMITH
Entity type:Organization
Organization Name:LAURA SMITH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEONR
Authorized Official - Middle Name:
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-525-8484
Mailing Address - Street 1:2444 E SOUTHERN AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-5418
Mailing Address - Country:US
Mailing Address - Phone:701-404-7550
Mailing Address - Fax:
Practice Address - Street 1:250 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1278
Practice Address - Country:US
Practice Address - Phone:575-525-8484
Practice Address - Fax:575-449-2445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty