Provider Demographics
NPI:1730815069
Name:SMITH, MIRREN EMMA-AILYSE
Entity type:Individual
Prefix:
First Name:MIRREN
Middle Name:EMMA-AILYSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 N OAKLAND AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1645
Mailing Address - Country:US
Mailing Address - Phone:303-242-0985
Mailing Address - Fax:
Practice Address - Street 1:21545 CENTRE POINTE PKWY
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91350-2947
Practice Address - Country:US
Practice Address - Phone:661-259-9439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program