Healthcare Provider Details

I. General information

NPI: 1841307196
Provider Name (Legal Business Name): MRS. GERALDINE MARIE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 LA JOLLA VILLAGE DR
SAN DIEGO CA
92161-0002
US

IV. Provider business mailing address

8975 LAWRENCE WELK DR SPC 11
ESCONDIDO CA
92026-6409
US

V. Phone/Fax

Practice location:
  • Phone: 858-642-3724
  • Fax:
Mailing address:
  • Phone: 760-751-2183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberRN485713
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: