Provider Demographics
NPI:1023368453
Name:SMITH, ANGELA BETH (CNP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:BETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 BROADWAY STE A6
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-3854
Mailing Address - Country:US
Mailing Address - Phone:707-599-6700
Mailing Address - Fax:707-798-6288
Practice Address - Street 1:3220 BROADWAY STE A6
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3854
Practice Address - Country:US
Practice Address - Phone:707-599-6700
Practice Address - Fax:707-798-6288
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA846580163WG0000X
CA23313363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN846580Medicaid
CARN846580Medicaid
CA103767Medicare PIN