1023509734 NPI number — MS. KIMBERLY TERSILLA SMITH AUD

Table of content: MS. KIMBERLY TERSILLA SMITH AUD (NPI 1023509734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023509734 NPI number — MS. KIMBERLY TERSILLA SMITH AUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
KIMBERLY
Provider Middle Name:
TERSILLA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
AUD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEDDA
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
TERSILLA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
AUD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023509734
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 EXPOSITION BLVD BLDG 700
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95815-4314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-736-3399
Provider Business Mailing Address Fax Number:
916-233-4171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10200 TRINITY PKWY STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95219-7288
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-952-0483
Provider Business Practice Location Address Fax Number:
209-478-5785
Provider Enumeration Date:
05/29/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  AU3301 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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