Provider Demographics
NPI:1629080999
Name:SMITH, KATHLEEN MOREAU (FNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MOREAU
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660879
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-0879
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:1200 W GONZALES RD
Practice Address - Street 2:STE 300
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-3072
Practice Address - Country:US
Practice Address - Phone:805-983-0691
Practice Address - Fax:805-983-2026
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP11751363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ34679ZOtherBLUE CROSS CALIFORNIA
CA110039977OtherMEDICARE RAILROAD
CARN247089Medicaid
CAWNP11751CMedicare PIN
CAZZZ34679ZOtherBLUE CROSS CALIFORNIA
CAWNP11751AMedicare PIN