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 1:15301 WARREN SHINGLE RD
Mailing Address - Street 2:
Mailing Address - City:BEALE AFB
Mailing Address - State:CA
Mailing Address - Zip Code:95903-1905
Mailing Address - Country:US
Mailing Address - Phone:530-634-4623
Mailing Address - Fax:
Practice Address - Street 1:15301 WARREN SHINGLE RD
Practice Address - Street 2:
Practice Address - City:BEALE AFB
Practice Address - State:CA
Practice Address - Zip Code:95903-1905
Practice Address - Country:US
Practice Address - Phone:530-634-4623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM63613363LP2300X
WVAPRN66962-NP-C363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care