Provider Demographics
NPI:1417606179
Name:SMITH, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 MEDICAL CENTER LN STE A
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-7390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29 MEDICAL CENTER LN STE A
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-7390
Practice Address - Country:US
Practice Address - Phone:256-571-8717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-180295163WP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health