Loading
Form preview picture

Get Cspmp Form

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.

How It Works

demographics rating
4.8Satisfied
59 votes

Tips on how to fill out, edit and sign DEA online

How to fill out and sign Cspmp Form online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Getting a authorized professional, making a scheduled visit and coming to the office for a private meeting makes doing a Cspmp Form from beginning to end tiring. US Legal Forms helps you to quickly make legally binding documents according to pre-constructed online samples.

Execute your docs within a few minutes using our easy step-by-step guide:

  1. Find the Cspmp Form you want.
  2. Open it up using the cloud-based editor and start adjusting.
  3. Complete the empty fields; engaged parties names, addresses and numbers etc.
  4. Customize the template with exclusive fillable fields.
  5. Put the date and place your electronic signature.
  6. Simply click Done after double-checking everything.
  7. Download the ready-created papers to your gadget or print it out like a hard copy.

Swiftly create a Cspmp Form without needing to involve professionals. We already have more than 3 million users benefiting from our unique collection of legal forms. Join us today and get access to the #1 library of web blanks. Test it yourself!

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Substances FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to Cspmp Form

  • az
  • np
  • demographics
  • Practitioner
  • Expiration
  • Mailing
  • Substances
  • digits
  • DEA
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.