Provider Demographics
NPI:1104223734
Name:SMITH, PATRICIA D (LIC INSURANCE AGENT)
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:LIC INSURANCE AGENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 296
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90223
Mailing Address - Country:US
Mailing Address - Phone:310-868-1423
Mailing Address - Fax:310-491-0555
Practice Address - Street 1:11436 HAWTHORNE BLVD., #288
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250
Practice Address - Country:US
Practice Address - Phone:310-868-1423
Practice Address - Fax:310-491-0555
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOB78888171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator