Provider Demographics
NPI:1508601808
Name:SMITH, DRIELLE
Entity type:Individual
Prefix:
First Name:DRIELLE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1255 KENDALL RD
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-8750
Mailing Address - Country:US
Mailing Address - Phone:805-781-3535
Mailing Address - Fax:
Practice Address - Street 1:1255 KENDALL RD
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-8750
Practice Address - Country:US
Practice Address - Phone:805-781-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-27
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker