Provider Demographics
NPI:1700393709
Name:SMITH, EVONNE D (IBCLC)
Entity Type:Individual
Prefix:
First Name:EVONNE
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:IBCLC
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 61281
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91116-7281
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 61281
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91116-7281
Practice Address - Country:US
Practice Address - Phone:626-808-4131
Practice Address - Fax:626-657-8184
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2024-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL-135842174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
1144920596OtherNPPES