Healthcare Provider Details

I. General information

NPI: 1568367530
Provider Name (Legal Business Name): NIKI SMITH
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2026
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 MORAGA AVE STE A204
SAN DIEGO CA
92117-5489
US

IV. Provider business mailing address

3737 MORAGA AVE STE A204
SAN DIEGO CA
92117-5489
US

V. Phone/Fax

Practice location:
  • Phone: 858-352-6438
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberL10081
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: