Provider Demographics
NPI:1407972805
Name:SMITH, MICHELLE MARIE (RN WHNP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-521-6097
Mailing Address - Fax:
Practice Address - Street 1:999 S FAIRMONT AVE
Practice Address - Street 2:235
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5100
Practice Address - Country:US
Practice Address - Phone:209-334-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14526363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABJ279Medicare PIN