Provider Demographics
NPI:1902029879
Name:SMITH, CHRISTINE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MARITIME ACADEMY DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-8181
Mailing Address - Country:US
Mailing Address - Phone:707-654-1170
Mailing Address - Fax:
Practice Address - Street 1:200 MARITIME ACADEMY DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-8181
Practice Address - Country:US
Practice Address - Phone:707-654-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11002363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ35075Medicare UPIN