Provider Demographics
NPI:1376397190
Name:SMITH, MABEL (NP)
Entity Type:Individual
Prefix:
First Name:MABEL
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 CHESTERTON AVE
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-2516
Mailing Address - Country:US
Mailing Address - Phone:650-863-2751
Mailing Address - Fax:
Practice Address - Street 1:1750 EL CAMINO REAL STE 15
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3208
Practice Address - Country:US
Practice Address - Phone:650-817-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029803363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty