Healthcare Provider Details

I. General information

NPI: 1114541554
Provider Name (Legal Business Name): KEILONI MARIE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E ALOSTA AVE
AZUSA CA
91702-2701
US

IV. Provider business mailing address

273 W ARROW HWY APT 80
AZUSA CA
91702-5469
US

V. Phone/Fax

Practice location:
  • Phone: 626-969-3434
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberY4201286
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberY4201286
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: