Healthcare Provider Details

I. General information

NPI: 1962011023
Provider Name (Legal Business Name): SHANEEKA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2020
Last Update Date: 07/24/2020
Certification Date: 07/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 POST ST APT 407A
SAN FRANCISCO CA
94109-6012
US

IV. Provider business mailing address

PO BOX 15156
SAN FRANCISCO CA
94115-0156
US

V. Phone/Fax

Practice location:
  • Phone: 410-564-8483
  • Fax:
Mailing address:
  • Phone: 410-564-8483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: