Healthcare Provider Details

I. General information

NPI: 1205691870
Provider Name (Legal Business Name): KRISTA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2136 CUTLER ST
SIMI VALLEY CA
93065-4923
US

IV. Provider business mailing address

10568 SAN LEANDRO ST
VENTURA CA
93004-2949
US

V. Phone/Fax

Practice location:
  • Phone: 805-539-3410
  • Fax:
Mailing address:
  • Phone: 805-708-0504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
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: