Basic Information
Provider Information
NPI: 1417463431
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SMITH
FirstName: NICOLE
MiddleName: M
NamePrefix:  
NameSuffix:  
Credential: RBT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4681 35TH ST APT 2
Address2:  
City: SAN DIEGO
State: CA
PostalCode: 921163540
CountryCode: US
TelephoneNumber: 2158737093
FaxNumber:  
Practice Location
Address1: 3978 SORRENTO VALLEY BLVD STE 100
Address2:  
City: SAN DIEGO
State: CA
PostalCode: 921211436
CountryCode: US
TelephoneNumber: 8584280222
FaxNumber:  
Other Information
ProviderEnumerationDate: 12/28/2017
LastUpdateDate: 12/28/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000XRBT-16-12732CAY    

No ID Information.


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