Provider Demographics
NPI:1134680622
Name:SMART, KAITLYN A (APN)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:A
Last Name:SMART
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:A
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:1900 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-5100
Mailing Address - Country:US
Mailing Address - Phone:217-280-8502
Mailing Address - Fax:
Practice Address - Street 1:1900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5100
Practice Address - Country:US
Practice Address - Phone:217-280-8502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019060363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner