Healthcare Provider Details

I. General information

NPI: 1508588575
Provider Name (Legal Business Name): ANGELICA SMULLIN MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 BEVERLY BLVD
WEST HOLLYWOOD CA
90048-1804
US

IV. Provider business mailing address

1053 18TH ST APT D
SANTA MONICA CA
90403-4448
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-3277
  • Fax:
Mailing address:
  • Phone: 707-601-5411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC001638
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: