Provider Demographics
NPI:1316388937
Name:SMITH, CHARLES E (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:SMITH
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15803 SOUTH MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248
Mailing Address - Country:US
Mailing Address - Phone:310-918-4298
Mailing Address - Fax:
Practice Address - Street 1:15803 S MAPLE AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-2534
Practice Address - Country:US
Practice Address - Phone:310-918-4298
Practice Address - Fax:310-538-1650
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005523363L00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty