Provider Demographics
NPI:1871038489
Name:SMITH, MAISHA JEANETTE (FNP)
Entity Type:Individual
Prefix:
First Name:MAISHA
Middle Name:JEANETTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 BUNYAN RD
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-3200
Mailing Address - Country:US
Mailing Address - Phone:530-252-2506
Mailing Address - Fax:
Practice Address - Street 1:1345 BUNYAN RD
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-3200
Practice Address - Country:US
Practice Address - Phone:530-252-2506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005773363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner