Provider Demographics
NPI:1194352591
Name:SMITH, LATISHA NICOLE
Entity type:Individual
Prefix:DR
First Name:LATISHA
Middle Name:NICOLE
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 1:2170 BIRCH RD APT 110
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-2034
Mailing Address - Country:US
Mailing Address - Phone:301-300-1199
Mailing Address - Fax:
Practice Address - Street 1:COMNAVSURFPAC
Practice Address - Street 2:2841 RENDOVA ROAD
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5490
Practice Address - Country:US
Practice Address - Phone:619-556-8449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61318754363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1194352591OtherTRI-CARE