Provider Demographics
NPI:1649399361
Name:SMITH, MARY GENENVIEVE (RNC, NNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GENENVIEVE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RNC, NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69696 PLEASANT GRV
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-2542
Mailing Address - Country:US
Mailing Address - Phone:760-770-3716
Mailing Address - Fax:
Practice Address - Street 1:1150 N INDIAN CANYON DR
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4872
Practice Address - Country:US
Practice Address - Phone:760-323-6430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA376530363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal