Provider Demographics
NPI:1083275630
Name:SMITH, KENNETH R (NP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 APPLE BLOSSOM DR
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79602-6009
Mailing Address - Country:US
Mailing Address - Phone:801-471-8870
Mailing Address - Fax:
Practice Address - Street 1:449 APPLE BLOSSOM DR
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79602-6009
Practice Address - Country:US
Practice Address - Phone:801-471-8870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9037845-8900363LA2100X
TXAP141978363LA2100X
NM70622363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care