Healthcare Provider Details

I. General information

NPI: 1265975148
Provider Name (Legal Business Name): DAISY KLITH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6065 HIGHWAY 193
GEORGETOWN CA
95634
US

IV. Provider business mailing address

PO BOX 45680
SAN FRANCISCO CA
94145-0680
US

V. Phone/Fax

Practice location:
  • Phone: 530-333-2548
  • Fax:
Mailing address:
  • Phone: 530-333-2548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number95005493
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95005493
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: