Provider Demographics
NPI:1891296901
Name:SMITH, KIMBERLY DIANE (ACUPUNCTURIST)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:ACUPUNCTURIST
Other - Prefix:
Other - First Name:K.D.
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ACUPUNCTURIST
Mailing Address - Street 1:1731 PICO BLVD APT 4
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-1629
Mailing Address - Country:US
Mailing Address - Phone:310-862-9269
Mailing Address - Fax:
Practice Address - Street 1:11110 OHIO AVE STE 105
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6345
Practice Address - Country:US
Practice Address - Phone:310-862-9269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11619171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist