Provider Demographics
NPI:1639709645
Name:NESMITH, ALYSIA NICOLE
Entity Type:Individual
Prefix:
First Name:ALYSIA
Middle Name:NICOLE
Last Name:NESMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3129 S HACIENDA BLVD # 412
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-6304
Mailing Address - Country:US
Mailing Address - Phone:626-715-9557
Mailing Address - Fax:
Practice Address - Street 1:3129 S HACIENDA BLVD # 412
Practice Address - Street 2:
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-6304
Practice Address - Country:US
Practice Address - Phone:626-715-9557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-17
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPA58139363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program