Provider Demographics
NPI:1528181757
Name:SMITH, TAMARA (LVN)
Entity Type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34111 WILDWOOD CANYON RD
Mailing Address - Street 2:#146
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-2644
Mailing Address - Country:US
Mailing Address - Phone:760-322-9065
Mailing Address - Fax:
Practice Address - Street 1:1330 N INDIAN CANYON DR
Practice Address - Street 2:SUITE A
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4880
Practice Address - Country:US
Practice Address - Phone:760-322-9065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN213023164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse