Healthcare Provider Details

I. General information

NPI: 1245051242
Provider Name (Legal Business Name): TRICIA ANNE SMALLWOOD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SUMMIT ST FL 2
OAKLAND CA
94609-3412
US

IV. Provider business mailing address

158 CRESTMONT DR LOWR APT
OAKLAND CA
94619-2312
US

V. Phone/Fax

Practice location:
  • Phone: 510-869-4000
  • Fax: 510-869-8475
Mailing address:
  • Phone: 631-880-1814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95032510
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: