Healthcare Provider Details

I. General information

NPI: 1093361438
Provider Name (Legal Business Name): CAMBRIA NICOLE SMITH LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 GLASSON WAY
GRASS VALLEY CA
95945-5723
US

IV. Provider business mailing address

13924 AUBURN RD
GRASS VALLEY CA
95949-8760
US

V. Phone/Fax

Practice location:
  • Phone: 530-470-2425
  • Fax: 530-265-7273
Mailing address:
  • Phone: 530-277-2704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number23-43956-031
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number1122
License Number StateVI
# 3
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number691026
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: