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ARIZONA STATE BOARD OF NURSING Application for Registration Access to the Arizona Controlled Substances Prescription Monitoring Program CSPMP FOR OFFICE USE ONLY PRINT CLEARLY USING CAPITAL LETTERS License Type NP CNM AP Certificate Number s / Expiration Date DEA Number SECURITY QUESTIONS M Mother s Maiden Name NPI Number Your Birth City 1. DEMOGRAPHICS Legal First Name Middle Name Last 4 Digits of SSN Date of Birth 2. PRACTICE ADDRESS Street Address Line 1 City State Work Phone Zip Code - County Fax Check here if Mailing Address is the same as PRACTICE ADDRESS 3. MAILING ADDRESS 4. Practitioner s Work or Personal Email Address If a Practitioner has multiple DEA numbers you MUST complete one form for each DEA number Submit Completed form s to Arizona State Board of Nursing 4747 N* 7th Street Suite 200 Phoenix AZ 85014-3655. DEMOGRAPHICS Legal First Name Middle Name Last 4 Digits of SSN Date of Birth 2. PRACTICE ADDRESS Street Address Line 1 City State Work Phone Zip Code - County Fax Check here if Mailing Address is the same as PRACTICE ADDRESS 3. MAILING ADDRESS 4. Practitioner s Work or Personal Email Address If a Practitioner has multiple DEA numbers you MUST complete one form for each DEA number Submit Completed form s to Arizona State Board of Nursing 4747 N* 7th Street Suite 200 Phoenix AZ 85014-3655.

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Keywords relevant to Cspmp Form

  • az
  • np
  • demographics
  • Practitioner
  • Expiration
  • Mailing
  • Substances
  • digits
  • DEA
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