Provider Demographics
NPI:1235135591
Name:SMITH, KATHLEEN J (ARNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:J
Other - Last Name:CRUMP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ARNP
Mailing Address - Street 1:3319 COLORADO BLVD
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-6817
Mailing Address - Country:US
Mailing Address - Phone:940-383-1279
Mailing Address - Fax:940-387-0489
Practice Address - Street 1:3319 COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-6817
Practice Address - Country:US
Practice Address - Phone:940-383-1279
Practice Address - Fax:940-387-0489
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP119931363L00000X, 363LA2100X
ARA03000 ANP363L00000X
WAAP30006856363LF0000X
TX550735363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR165788741Medicaid
WA9643750Medicaid
OK200114220AMedicaid
WA9643750Medicaid
AR5A441Medicare PIN
AR165788741Medicaid