Provider Demographics
NPI:1346680519
Name:SMIRNOV, KSENIA (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:KSENIA
Middle Name:
Last Name:SMIRNOV
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 MASON DR
Mailing Address - Street 2:
Mailing Address - City:WARMINSTER
Mailing Address - State:PA
Mailing Address - Zip Code:18974-2706
Mailing Address - Country:US
Mailing Address - Phone:267-243-0671
Mailing Address - Fax:
Practice Address - Street 1:9880 BUSTLETON AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-2185
Practice Address - Country:US
Practice Address - Phone:215-677-0667
Practice Address - Fax:215-677-1063
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP012947363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health