Provider Demographics
NPI:1528442761
Name:SMITH, EDWINA (RN)
Entity type:Individual
Prefix:MRS
First Name:EDWINA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12258 BALI ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-6836
Mailing Address - Country:US
Mailing Address - Phone:760-995-8300
Mailing Address - Fax:760-955-2356
Practice Address - Street 1:12625 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7720
Practice Address - Country:US
Practice Address - Phone:176-099-5830
Practice Address - Fax:760-955-2356
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA464831163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse