Provider Demographics
NPI:1790342830
Name:SMITH, CLYDE R (BS, MSN, RN-BC)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:BS, MSN, RN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 KOKOMO DR APT 411
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95835-1822
Mailing Address - Country:US
Mailing Address - Phone:814-227-7636
Mailing Address - Fax:
Practice Address - Street 1:6501 COYLE AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0306
Practice Address - Country:US
Practice Address - Phone:916-537-5014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95183506163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse