Healthcare Provider Details

I. General information

NPI: 1972740850
Provider Name (Legal Business Name): THERESE LEE SMITH RN,PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 01/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 BROADWAY STE 1300
SACRAMENTO CA
95820-1527
US

IV. Provider business mailing address

4600 BROADWAY STE 1300
SACRAMENTO CA
95820-1527
US

V. Phone/Fax

Practice location:
  • Phone: 916-874-9948
  • Fax:
Mailing address:
  • Phone: 916-874-9948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number519508
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: