Healthcare Provider Details

I. General information

NPI: 1215779673
Provider Name (Legal Business Name): MICHELLE EASTMAN-SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2024
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19901 1ST ST STE 4
HILMAR CA
95324-9099
US

IV. Provider business mailing address

PO BOX 3768
MERCED CA
95344-3768
US

V. Phone/Fax

Practice location:
  • Phone: 209-656-8701
  • Fax:
Mailing address:
  • Phone: 209-725-7149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95066370
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: