Provider Demographics
NPI:1114464179
Name:SMITH, PENNY (FNP)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 LAURSEN ST
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4437
Mailing Address - Country:US
Mailing Address - Phone:951-929-5537
Mailing Address - Fax:951-929-9761
Practice Address - Street 1:361 N SAN JACINTO ST
Practice Address - Street 2:STE A,B & C
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-3118
Practice Address - Country:US
Practice Address - Phone:951-492-0728
Practice Address - Fax:951-492-0745
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-27
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005801363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty