Provider Demographics
NPI:1477184919
Name:SMITH, SEAN ARTHUR
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:ARTHUR
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11962 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-2914
Mailing Address - Country:US
Mailing Address - Phone:619-561-1222
Mailing Address - Fax:619-390-8663
Practice Address - Street 1:11962 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-2914
Practice Address - Country:US
Practice Address - Phone:619-561-1222
Practice Address - Fax:619-390-9487
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-03
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA689343164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse