Provider Demographics
NPI:1710025432
Name:SMITH, DIANNE VERNALENE (MS)
Entity Type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:VERNALENE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15034 PROVIDENCE LN
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-3477
Mailing Address - Country:US
Mailing Address - Phone:818-773-9080
Mailing Address - Fax:
Practice Address - Street 1:15034 PROVIDENCE LN
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-3477
Practice Address - Country:US
Practice Address - Phone:818-773-9080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU1422231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU0014220Medicaid
CAAUD1422Medicare ID - Type UnspecifiedAUDIOLOGY