Provider Demographics
NPI:1437289584
Name:SMITH, NICOLE ANNETTE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ANNETTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:ANNETTE
Other - Last Name:FITZGERALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1542 LA COSTA CIR
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-8047
Mailing Address - Country:US
Mailing Address - Phone:909-931-1553
Mailing Address - Fax:
Practice Address - Street 1:7777 B MILLIKEN AVE ST 240
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-941-0247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 17734363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical