Provider Demographics
NPI:1083034946
Name:SMITH, KAITLYN
Entity Type:Individual
Prefix:
First Name:KAITLYN
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 1:105 RAIDER BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NJ
Mailing Address - Zip Code:08844-1528
Mailing Address - Country:US
Mailing Address - Phone:973-479-1129
Mailing Address - Fax:
Practice Address - Street 1:765 ROUTE 10 E
Practice Address - Street 2:STE 201
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-1925
Practice Address - Country:US
Practice Address - Phone:973-479-1128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-18
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00498600363L00000X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care