Provider Demographics
NPI:1447852074
Name:SMITH, STEPHANIE CAITLIN (NP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CAITLIN
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 S SAN PEDRO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-2023
Mailing Address - Country:US
Mailing Address - Phone:323-233-3100
Mailing Address - Fax:323-233-4100
Practice Address - Street 1:2098 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-1235
Practice Address - Country:US
Practice Address - Phone:323-233-3100
Practice Address - Fax:323-233-4100
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015812363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550003832Medicaid