Provider Demographics
NPI:1508528621
Name:SMITH, ASHLEY NICOLE (LAC)
Entity Type:Individual
Prefix:MS
First Name:ASHLEY
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10770 NORTHGATE ST
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-5484
Mailing Address - Country:US
Mailing Address - Phone:512-799-9753
Mailing Address - Fax:
Practice Address - Street 1:13323 W WASHINGTON BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5144
Practice Address - Country:US
Practice Address - Phone:512-799-9753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC19249171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist