Healthcare Provider Details

I. General information

NPI: 1740446509
Provider Name (Legal Business Name): MIJA GOLDSMITH CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 SAN JULIAN ST
LOS ANGELES CA
90015-3142
US

IV. Provider business mailing address

3706 S PATTON AVE
SAN PEDRO CA
90731-6034
US

V. Phone/Fax

Practice location:
  • Phone: 213-765-2800
  • Fax: 213-765-3861
Mailing address:
  • Phone: 310-519-1384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LS0200X
TaxonomySchool Nurse Practitioner
License Number12845
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: