Provider Demographics
NPI:1366453029
Name:SMERKO, KATHLEEN ANN (MS, PSY NP BC)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANN
Last Name:SMERKO
Suffix:
Gender:F
Credentials:MS, PSY NP BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 E MISSOURI AVE
Mailing Address - Street 2:STE 640
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2735
Mailing Address - Country:US
Mailing Address - Phone:602-235-9505
Mailing Address - Fax:602-235-9506
Practice Address - Street 1:1110 E MISSOURI AVE
Practice Address - Street 2:STE 640
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2735
Practice Address - Country:US
Practice Address - Phone:602-235-9505
Practice Address - Fax:602-235-9506
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN071540363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
425240Medicare UPIN
21250Medicare ID - Type Unspecified