Provider Demographics
NPI:1992430664
Name:SMITH, MADALYN MARIE
Entity type:Individual
Prefix:
First Name:MADALYN
Middle Name:MARIE
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 1:1245 WILSHIRE BLVD STE 703
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4807
Mailing Address - Country:US
Mailing Address - Phone:213-977-0419
Mailing Address - Fax:213-977-0225
Practice Address - Street 1:1245 WILSHIRE BLVD STE 703
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4807
Practice Address - Country:US
Practice Address - Phone:213-977-0419
Practice Address - Fax:213-977-0225
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95021723363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care