Provider Demographics
NPI:1598525891
Name:SMITH, MEGHAN MACKENZIE (PNP)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:MACKENZIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:MEGHAN
Other - Middle Name:MACKENZIE
Other - Last Name:NUNEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20061 MARINA LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-4702
Mailing Address - Country:US
Mailing Address - Phone:949-378-8668
Mailing Address - Fax:
Practice Address - Street 1:1640 NEWPORT BLVD STE 360
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3786
Practice Address - Country:US
Practice Address - Phone:949-515-7337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029077363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics