Provider Demographics
NPI:1891156352
Name:SMITH, BREA TRINITY (PNP)
Entity Type:Individual
Prefix:
First Name:BREA
Middle Name:TRINITY
Last Name:SMITH
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11234 ANDERSON ST
Mailing Address - Street 2:ROOM 6700 H
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2804
Mailing Address - Country:US
Mailing Address - Phone:909-558-8514
Mailing Address - Fax:909-558-7873
Practice Address - Street 1:700 E GILBERT ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-1003
Practice Address - Country:US
Practice Address - Phone:909-382-3535
Practice Address - Fax:909-383-3830
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA761340363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics