Provider Demographics
NPI:1154963361
Name:SMITH, NICOLE MAE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20349 BARREL RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0109
Mailing Address - Country:US
Mailing Address - Phone:530-604-1153
Mailing Address - Fax:
Practice Address - Street 1:22445 ALESSANDRO BLVD
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-8358
Practice Address - Country:US
Practice Address - Phone:951-924-9791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator