Provider Demographics
NPI:1114514445
Name:SMITH, KEVIN LEE SR
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:SMITH
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3612 S 14TH ST APT 210
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-1087
Mailing Address - Country:US
Mailing Address - Phone:301-732-3414
Mailing Address - Fax:
Practice Address - Street 1:2 M ST NE APT 524
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-3985
Practice Address - Country:US
Practice Address - Phone:301-732-3414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAF696153013747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant