Provider Demographics
NPI:1376945261
Name:SMITH, KENNETH II (DNP)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:SMITH
Suffix:II
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 W D.L. INGRAM AVE
Mailing Address - Street 2:
Mailing Address - City:CANNON AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88103-5103
Mailing Address - Country:US
Mailing Address - Phone:575-784-1104
Mailing Address - Fax:
Practice Address - Street 1:224 W D. L. INGRAM AVE
Practice Address - Street 2:
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103-5103
Practice Address - Country:US
Practice Address - Phone:575-784-1104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN66962-NP-C363LP2300X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care