Provider Demographics
NPI:1760870091
Name:SMITH, NIKITA (FNP-C)
Entity Type:Individual
Prefix:
First Name:NIKITA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5055 TISELLE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-5322
Mailing Address - Country:US
Mailing Address - Phone:504-231-3807
Mailing Address - Fax:
Practice Address - Street 1:1524 W LACEY BLVD
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-5965
Practice Address - Country:US
Practice Address - Phone:559-537-0284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-09
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95071841363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily