Provider Demographics
NPI:1003521238
Name:SMITH, KRISTENE
Entity Type:Individual
Prefix:
First Name:KRISTENE
Middle Name:
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 1:100 LAVENPORT CIR
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-5100
Mailing Address - Country:US
Mailing Address - Phone:240-418-3111
Mailing Address - Fax:
Practice Address - Street 1:800 S FREDERICK AVE STE 200A
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-4116
Practice Address - Country:US
Practice Address - Phone:877-588-0282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR177846363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health