Provider Demographics
NPI:1285056911
Name:SMITH, KENYA DENETTE
Entity type:Individual
Prefix:
First Name:KENYA
Middle Name:DENETTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KENYA
Other - Middle Name:DENETTE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:5000 VAN NUYS BLVD STE 305
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1717
Mailing Address - Country:US
Mailing Address - Phone:818-480-6456
Mailing Address - Fax:818-205-1924
Practice Address - Street 1:5000 VAN NUYS BLVD STE 305
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1717
Practice Address - Country:US
Practice Address - Phone:818-480-6456
Practice Address - Fax:818-205-1924
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA578715163W00000X
CA95000220363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse