Healthcare Provider Details

I. General information

NPI: 1619555240
Provider Name (Legal Business Name): SMITAL S SONI FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 03/28/2022
Certification Date: 06/29/2021
Deactivation Date: 05/24/2021
Reactivation Date: 06/10/2021

III. Provider practice location address

340 S LEMON AVE
WALNUT CA
91789-2706
US

IV. Provider business mailing address

340 S LEMON AVE
WALNUT CA
91789-2706
US

V. Phone/Fax

Practice location:
  • Phone: 415-870-2437
  • Fax:
Mailing address:
  • Phone: 415-870-2437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209023295
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.023295
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number041.465350
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: