Healthcare Provider Details

I. General information

NPI: 1073104097
Provider Name (Legal Business Name): KEIANA SHARICE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 02/02/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 E. COLORADO BLVD. SUITE 560 PASADENA, CA
PASADENA CA
91106-9110
US

IV. Provider business mailing address

1055 E. COLORADO BLVD. SUITE 560 PASADENA, CA
PASADENA CA
91106
US

V. Phone/Fax

Practice location:
  • Phone: 818-241-6780
  • Fax: 818-241-6853
Mailing address:
  • Phone: 818-241-6780
  • Fax: 818-241-6853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: