Provider Demographics
NPI:1508383290
Name:SMITH, MICHELE LYNN PETTIT (RN)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LYNN PETTIT
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:LYNN
Other - Last Name:PETTIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2890 GATEWAY OAKS DR STE 250
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-4328
Mailing Address - Country:US
Mailing Address - Phone:855-421-6831
Mailing Address - Fax:
Practice Address - Street 1:2890 GATEWAY OAKS DR STE 250
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95833-4328
Practice Address - Country:US
Practice Address - Phone:855-421-6831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA523518163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse